Online CS Consultation on the Global health Theme of the Post 2015 UN Agenda Global Health South (The Alliance of Southern CS in Global Health)/CHESTRAD in partnership with Campaign 2015+ and the Call for Action on Universal Health Coverage With Support from the Health Thematic Group, Post 2015 UN Agenda The Health theme of the Post 2015 agenda, convened by WHO and UNICEF with support from the Government of Botswana and the Government of Sweden, have supported Global Health South, an alliance of Southern CS in global health (www.globalhealthsouth.org), hosted by the Centre for Health Sciences Training, Research and Development (CHESTRAD) (www.chestrad-ngo.org) in partnership with Campaign 2015+ and the Call for Action on Universal Health Coverage, a global CS initiative lead by the Action for Global Health in partnership with Medecins du Monde, the Centre for Health & Social Services (CHeSS), Medicus Mundi International, Oxfam, Save the Children and Management Sciences for Health to host a CS consultation on global health in the post 2015 UN agenda. Actions included an online consultation targeting the CS database of Global Health South, members of Campaign 2015+, proactive outreach to the global CS community working with agencies, global health initiatives and existing CS networks, review of submissions to the health and related themes to on-going consultations on the www.worldwewant2015.org, www.beyond2015.org as well as outcome statements and report from by the implementing partners of the consultation. Participants were also encouraged to submit documentation of their own experiences, lessons and organizational considerations on the priorities for global health in the post 2015 agenda. The consultation was open from the 9th of December 2012 to 11th January 2013. The online outreach targeted a total of 785 institutions across partner organizations and networks and attracted participation from over 180 organizations active across 48 countries, a participation rate of 22.9%. Engagement from community based and regional organizations in Africa was active, constituting 69.5% of all participants, Latin American & the Caribbean (8.6%), South East Asia (8.0%), Europe (6.9%) and from North America and Canada (8.0%). Regional participation is representative of membership of Global Health South and CS and other related institutions included in its consultation database. Support for analysis and reporting was provided by ResultsLab (www.resultslab.co) The draft findings of the consultation were disseminated online to participants and a more focused face to face meeting involving selected participants and southern CS representatives of global agencies, programs, delegations, boards and fora is further proposed as a part the engagement of southern CS, institutions and governments in the fast paced and critical dialogue on global health in the post 2015 UN agenda. Key Messages from the Online Consultation 1. The headline messages from the online CS Consultation are: i. There is no strong support for one health goalframed around Universal Health Care. There was however stronger support for the concept of ‘universality’ identified as ‘access, coverage, equity (income, gender and geographic), social protection and financial protection’as a framing principles for the health goals. There is though strong support for the post-MDG agenda to maintain continuity with the MDGs as it is regarded as unfinished business ii. There is a very clear emphasis given to prioritising the needs of women and children, specifically maternal and child health and sexual and reproductive health and rights keeping also in focus access of the general population to a basic package of care. In addition, there is strong recognition of the importance of ensuring access to health services for other vulnerable groups, for example people with disabilities. iii. There are strong calls to broaden the focus of the goals towards health systems strengthening and away from disease- and issue specific interventions. iv. Strong support is given to the importance of amultisectoral action for health, alongside recognition of the need to address the socio-economic determinants and the rapidly evolvingeconomic realities between countries. v. It is important that the post-MDG goals take into account the context in which action will be taken, are founded on guiding principles that are adaptable at the national level, and flexible for local implementation. They should also be based on shared, coherent understanding that enables global level solidarity and differentiated accountable action where necessary and appropriate. 2. The CS online consultation on the Global Health theme included messages to the High Level Panel, which stress the importance of a change oriented process that centres on values such as equity, participation, partnership, accountability, human rights and human security - where CSOs are 'at the table' at all levels. The survey points towards the importance of broader, more inclusive partnerships and that effective accountability is central to this. These principles were also explored in the responses on who should lead. The dominant theme from the CS consultation emphasized the importance of participatory processes and inclusive structures that support partnership values. There were mixed views on which organization is best placed to take the lead 3. The CS online consultation gives emphasis and focused priority toglobal health governance including alignment and coordination processes, calling for renewed attention to accountability, coordination and partnerships as well as participation and inclusive processes. The online CS consultation proposed options that can be considered on how this should be shaped in the new agenda 4. When reviewing the rich data gathered by the survey, alongside thesubmissions made to the health theme on the World We Want website [1] a coherence and shared agenda appears to be emerging. This is most notable in relation to equity, human rights, human security,health systems, sexual and reproductive health, accountability andimproved global health governance. 5. The very large consultation response provides an opportunity for the voice of Southern Civil Society to be heard in negotiations on the post-2015 agenda. It provides valuable perspectives (with regional variations) from the experience of Southern Civil Society on a range of issues relating to the post MDG agenda (based on 181 responses), in particular from sub-Saharan Africa. The report can be used to help qualify and prioritise responses that have been submitted to the Health Thematic Consultation and can inform the development of a Civil Society position as negotiations on the post-MDG agenda move to the national level. Summary of Key Findings Achievements and Lessons Learnt • The strongest support was for achievements made in increasing access to life saving interventions, and in reducing child mortality. The lowest support was for the impact on mobilizing resources and attention/investment for development. • There was a difference of opinion in the views of the northern and southern respondents on the achievements of the MDGs. • Civil Society respondents, in the open-ended section, report that they have made significant contributions to these achievements. • Stand out lessons learnt include: 1) Financial resources need to be better linked to produce results; 2) Weak health systems have constrained universal access to health inputs and other life-saving interventions; 3) Universal coverage, access and equity still remain concerns. • CSOs expressed strong views that they should be part of incorporating these lessons learnt into future practice, either through being included and/or by making themselves heard. Linked to this, there is weight placed on the way processes, like the development of post 2015 agenda, are implemented, especially, commitments to principles of accountability, aid effectiveness and global health governance. Health Priorities for the Post-2015 Development Agenda • ‘Universality’. Access, coverage, equity, social protection and financial protection were the principles with the strongest support - with access having the highest average response. There was strong convergence on this across the 5 regions. • Disease specific priorities. HIV/AIDS and other STIs, Immunization and Malaria were the disease priorities with strongest support. Non-Communicable Diseases and Neglected Tropical Diseases were ranked as lower priorities. There was more regional divergence over the ranking of these priorities. Qualitative responses significantly emphasised a focus on women and, maternal health, the health of adolescents and young persons and other communicable diseases. • Health Systems Strengthening priorities. Human Resources for Health (HRH), Medicines and Medical Supplies and Integrated, and comprehensive, costed national health plans were the top three health systems strengthening priorities. Quality Management and strengthening the Health Management Information System were ranked lowest. There was strong agreement on the importance of all of the options offered, with HRH receiving very strong support across all regions. Qualitative responses emphasised well-resourced systems and structures that meet the needs of specific population groups and enable collaboration and empowerment. • Issue focused priorities. Sexual and Reproductive Health (SRH), Maternal and Newborn Health (MNH) and Primary Health Care (PHC) were the top three issue focused priorities. Also of high, but less priority are Child & Adolescent health and Nutrition. Areas of lowest priority are recorded as Mental health & violence, and the application of technology Qualitative responses emphasized women’s access to appropriate sexual and reproductive health and the related interventions. Measuring Progress • The highest priority was given to a health goal that highlights the intersectorality of investment in health. The lowest priority was given to One health goal (Universal Health Care) with targets that monitor progress on priority health burdens and issues. There was a high degree of divergence across the five regions on the relative priorities of the suggested options. • There were few qualitative responses on to this question. This is in marked contrast to the submissions that were made to the World We Want website. • The highest priority criteria were reported as Access, Equity, Coverage and Human Resources for Health. The lowest rated criterion was life expectancy. The ‘southern’ regions consistently attached higher importance across these criteria. For the majority of criteria Western Europe and North America reported different priorities compared to the ‘southern’ regions. • On ‘age for target group’ the top three average priorities are: infants, under 5s, and women (18-64). The clear lower priorities are Men (18-64), Aged and the general population. There was some regional variation noted. Qualitative responses emphasised health as a human right for all, calling for improved access for all people as well as improved targeting of women, children and young people. Integrating Health into the Sustainable Development Goals/Agenda • The top two contexts of most relevance were recorded as ‘economic realities’ and ‘unfinished business’. Those of lowest relevance were ‘Significant change in global architecture’ and ‘More globalized and interconnected world’. • The top priorities for guiding principles and measurement indicators were Human Rights & security, Empowerment & Sustainable livelihoods, and Universality & Equity. There was strong support across all regions for all of the options offered in the survey. Western Europe and North America regularly provided lower ratings than the other regions. • Qualitative responses on how to improve the collection, analysis and management of indicators including dissemination and its use by civil society organizations and civic populations emphasized the importance of resources for making the collection, storing and analysing data accessible and an emphasis on training for, and continuing commitment to monitoring and evaluation. Accountability for Global Health • Accountability, development financing and sustainable development were the top rated principles in relation to increasing ownership. • All of the options for institutional arrangements for accountability and responsibility received strong support, with ‘A framework for international development that includes shared but differentiated accountability and responsibilities for national governments, development partners and citizens’ receiving the highest average score. • There was notably little support for the ‘none of the above’ option in this area – suggesting strong support for accountability in principle, but the limited number of qualitative responses and suggestions under ‘Other’ indicate that there may be limited understanding about how to strengthen accountability. Civil Society and the Development Agenda • The options with the strongest support on civil society’s role were: Policy advocacy and dialogue, Development effectiveness and accountability; Research, evidence and performance management, and Knowledge management, brokering and learning. The option with the least support was service delivery. Innovation and capacity enabling and leadership development received the same average score. • There was considerable regional variation in scoring each option. Perhaps unsurprisingly there was more consistent strong support for policy, advocacy and dialogue. Global Health Architecture, Partnership and Governance • There were 137 valid responses to the [1]open-ended question on the number of organizations and partnerships engaged in health at global and national levels, who should lead interlinked priorities in health, and how leadership should be structured and managed. The dominant response acknowledged the increased fragmentation in global health and the impact this has on country level action. It also emphasised the importance of participatory processes and inclusive structures that supported partnership values. There was a mix of views on institutional arrangements with some favouring global leadership, some favouring national, and some proposing structures that facilitated joint global-national leadership. The following quotes highlight some of these themes. ‘I do not see an issue in the number of stakeholders active in health sector, but rather weak coordination of global and national efforts’ ‘I do not agree with this statement. We must promote the richness in diversity and seek optimization and coordination’ ‘Global Partnerships for health helped secure additional resources and more inclusive engagement of civil society’. Global health partnerships have been one of the great success stories of the past decade!’ 'This is a statement of reality and unfortunately the situation has been precipitated by the lack of mutual accountability. The space for multiple partnerships and stakeholders in health has been created by the pre MDGs era and belief that the partners with the mandate for the work did not have the capacity to handle the response to the health challenges. Each partner has a role to play in health and sub-Saharan Africa has in the last 2 decades increased it capacity (human and other resources) to respond to the health challenges. The proposed structure should have WHO and UN providing support to national governments to implement programmes that respond to the national strategy with a large percentage of the work being done be the national government to reduce the cost of delivering universal access. Civil society contributing to the national strategies of health by providing support to government in addressing the unmet needs in services, access and geographical coverage. All partnerships addressing health should be coordinated and brought under one umbrella for greater health impact and pooling of resources, Integration should be the tenet of all global initiatives.' ‘This statement is very true. Structure of leadership sometimes are not the problem but the culture in which implementation takes place. There has to be an honest in-depth social analysis that appreciates attitudes around corruption and poverty that influence implementation from the very top to the bottom. Right now communities are tired of the corruption but do not know how to stop it, engaging communities and having community level accountability is very important. Partners have to work more as partners instead of financiers of projects. Once partnerships are redefined, our work on the ground will look different’. ‘Yes I do. The World Health Organization, being the flagship UN agency for health, should retain control over the management and coordination of these partnerships in health. The governance structure should be spearheaded by the WHO and supported by the WHO Regional and country Offices, in collaboration with all other partner agencies and organizations, including civil society.’ ‘UN should lead the interlinked priorities in health. Form equal partnership of government and civil society’ Messages for the High Level Panel The survey invited respondents to rank key CS messages for the health thematic consultation of the Post-2015 development agenda. The three messages with the strongest support were: Universal health: access coverage and equity, Healthy People! Wealth Nations! The least support was for the Global health architecture: ownership results and accountability. As present in the rest of the survey, there was strong regional variation in the support expressed for each of the key messages. However, in most cases Western Europe and North America rated the key messages lower than the ‘southern regions’. The survey then invited respondents to include 3 other messages to share with the High-level Panel of Eminent Persons on the Post-2015 Development Agenda. A substantial number of respondents took the opportunity to provide additional feedback to the panel. Given this question sought input in relation to the process of the post 2015 agenda, more than two-thirds of the messages to the panel are process oriented rather than statements of vision. However, the processes and ideas put forward are change oriented and centre on values such as equity, participation, partnership, accountability and human rights - whereby CSOs are 'at the table' at all levels and where the population groups as the focus for change is on women and most at risk populations. The other theme emerging is the emphasis on local context as the key setting for action, with CSOs being key to the success of any action. Some examples of responses include: ‘The MDGs have been highly effective, catalysing unprecedented action and accountability for the development process – lets complete this agenda’ ‘Accountability and Responsibility: All must have a say; all must commit to their roles’ ‘Every group of people must have input into any decision that affects them, their voices must be heard and their contribution must count’ ‘Stigmatization of minority social groups must be outlawed. Infrastructural Support for Wireless Networking is imperative to achieving the MDG/post-2015 Agenda targets. CSOs must form lobby group coalitions to effectively influence state legislation in the enforcement of MDG/post-2015 Agenda targets.’ ‘The High Level Panel must ensure that new goals and targets can address the roots causes off ill-health by Reducing child mortality from infectious causes by strengthening the ability of health systems to address the social and environmental determinants of health, and by focusing on prevention rather than over-emphasising easily-counted treatment interventions, while also ensuring that lifesaving and life-prolonging treatment is available to all who need it.’ ‘ Health for All: it is the small but determined and committed steps that count!!!’ ‘Girls and women are at the heart of development. Healthy mothers bring about healthy families, communities and nations. Access to family planning is a cost-effective, life-saving solution to ending maternal deaths and bringing about positive health, social, and financial outcomes to a nation. ‘ ‘Health as human right issue. Health Equity. Addressing emerging challenges of non-communicable diseases.’ ‘The political causes of poverty and its resulting ill health must be a starting point for improving health. Despite the many obstacles to achievement, genuine country ownership of their own economic and health policies must be the main aim of development, including health development. Setting universal goals such as those of the MDGs is counterproductive because it does not acknowledge the importance of the first two messages.’ ‘Maternal mortality (and morbidity) is one of the best indicators of the state of a nation's heath system. It measures how well a nation takes care its people at their most vulnerable. Good maternal care also requires all the components of a strong health system including locally available, affordable care, effective referral mechanisms, adequately trained health workers and a sustained supply of the necessary commodities. Under-five mortality is a good composite development indicator, as it reports not only on preventive health and curative care but also on wider development issues e.g. female literacy, access to food and the availability of clean water. As such the state of a nation can be measured by trends in under five mortality.’ ‘Accountability must exist for all countries. To the extent that states are not at fault hardly react. Civil society should create and strengthen mechanisms for participation. The agencies of the United Nations cannot validate the lack of transparency and accountability of states.’ ________________________________________ [1] Currently, there are a plethora of organization programme and partners leading diseases and issues in global health. Overtime, the focus and mandate of these organizations have overlapped, often resulting in competition for resources, fragmentation of services, increasing response burden and limiting accountability of development partners, national governments, civil society and other stakeholders. Do you agree with this statement? In your opinion, who should lead the interlinked priorities in health? How should this leadership be structured?