Accountability Under Universal Health Coverage: Determining What Role Civil Society Must Play

Action for Global Health, convened a civil society meeting at the World Health Assembly, in coordination with the Global Health Council highlighting the role of civil society in holding governments accountable for the provision, coverage and quality of care under Universal Health Coverage (UHC).

The event entitled; "Accountability under Universal Health Coverage: Determining what role civil society must play", built on the inspiration from our recent civil society meeting in Dakar, addressed three key messages:

•    best practice of civil society engagement in accountability mechanisms;
•    main challenges of community-led monitoring and accountability;
•    ‘non-negotiable’/unacceptable trade-offs in terms of accountability and civil society participation.

The meeting was opened by Tim Roosen, Coordinator of Action for Global Health, who called for community-driven UHC emphasising the need for meaningful, participatory decision-making and prioritising vulnerable and marginalised groups; which is crucial for UHC to deliver the right to health for all.

Panellists discussed key points about the different levels of accountability on a country-by-country basis, the need for increased dialogue, and the basic package of services that should be made available.


Accountability and Governance

Accountability is not only about monitoring but ensuring governments are answerable to the commitments they have made. UHC has to do with inequity, and is therefore inherently political. UHC means equity, which means a distribution of resources - for that we need strong civil society input.

Executive Director of the Global Health Council, Christine Sow stressed that civil society cannot be treated as a static block: “When asking civil society organisations to play an accountability role we have to recognise they have a vested interest with their communities, and have their own role to play with their governments.”

The inability of many African Civil Society Organisations to raise their voice for fear of reprisals, which include government funding cuts, was also highlighted by African civil society participants. Consulting with civil society from the South is an onerous task, especially when they are not mandated and there is a penalty to pay for airing their voices. In addition, civil society is not a homogenous group – not all CSOs are implementing accountability work; many are delivering services.

Experiences of mechanisms within accountability

Having formal mechanisms around accountabilities can help provide space for civil societies to speak up. There are also different mechanisms for UHC accountability - there is the global level and the country level.

In developing countries, there is a mobile middle class and their conception of UHC is a hospital where everything works well.  What works for an urban population does not always work for a rural populations was echoed by Karen Kavanagh, USAID

Finn Schleimann of the World Bank and IHP+ underlined the importance of civil society participating in planning processes: “IHP+ mobilises national governments, development agencies and civil society to support a single, country-led national health strategy. IHP+ strongly believes aligning with country strategies will produce better results, as it strengthens national planning and harmonises financial management.” He concluded with three challenges to CSOs: the need for issue and disease-specific CSOs to focus on cross- cutting health systems issues; increasing capacity in health CSO networks and broad health systems focused engagement, and increasing financing for CSOs in low-income countries.

Enabling environment

The need for enablers, strong targets and commitments was stressed– such as UHC, the right to health and universality. The huge community-driven response to key populations living with HIV/AIDS highlighted by David Ruiz of the HIV/AIDS Alliance shows best practice, and is now reflected in global governance structures such as UNAIDS and the Global Fund.

“We need to connect the dots: from the governance structures to the HIV/AIDS response to UHC,” was reaffirmed by John Jay, Management Sciences for Health (MSH).

Although the WHO’s monitoring framework is commendable, there was a resounding consensus from the meeting that we need 100% coverage not 80% of the bottom 40%. This appears to be a step backwards rather than forwards.

There is a missed opportunity with the framework to provide an enabling environment for meaningful civil society participation.

As Charlotte Soulary, Oxfam International put it: “If we are not going to fight now for strong targets then we will have nothing in post-2015 to fight for.”

The questions raised and ideas discussed will be taken forward by Action for Global Health alongside The Global Health Council at the UNGA.

Click to read WHO Director-General address at the Sixty-sixth World Health Assembly