Advancing Health Equity: The Framework Convention on Global Health

1. Towards Health Equity Through a Framework Convention on Global HealthAttiya WarisMember, JALI Steering CommitteeSenior Lecturer, School of Law, University of Nairobi IHP+ Civil Society Consultative Group Meeting December 10-11, 2012, Nairobi, Kenya

2. Overview • What is the Framework Convention on Global Health (FCGH)? • Why an FCGH? • The FCGH, from proposal to law • Post-2015 development agenda • Towards the FCGH itself

3. A Framework Convention on Global Health: The Basics

4. Background to the FCGH: Persisting Health Inequities and Challenges • Health inequities • Life expectancy in Sub-Saharan Africa (2011): 54 years • Life expectancy in high-income countries (2008): 80 years • Continued and emerging global health challenges • Pressures requiring global response • Growing but insufficient funding • Health worker migration • Population growth • Trade and intellectual property (access to medicines) • Global industry (e.g., tobacco, “big food”)

5. Background to the FCGH: Global Response Required and Possible • Power of law • Framework Convention on Tobacco Control • 176 countries party to FCTC • Action: more than 60% of 72 long-term state parties have increased tobacco taxes and expanded smoke-free public places • Right to health • Responsibilities lack precision, especially global responsibilities

6. Framework Convention Approach • Therefore, proposal for a Framework Convention on Global Health (FCGH) • FCGH would be a legally binding global treaty • Could establish norms that create pressure for countries not ratifying (i.e., formally agreeing to be bound by the treaty) FCGH to follow nonetheless • Framework convention/protocol approach • Initial framework convention establishes key principles, goals, processes of the legal regime • May also include specific, detailed commitments • Later protocols, which countries would need to separately ratify, provide additional detail on commitments or address relevant issues not adequately addressed in initial framework convention • Useful approach for complex and evolving field of global health

7. Joint Action and Learning Initiative on National and Global Responsibilities for Health (JALI) • In response, coalition forms JALI • What is JALI? • A global civil society-led coalition advocating for and supporting development of a Framework Convention on Global Health • Committed to an ambitious treaty that will truly be grounded in the right to health • Initiating broad and inclusive process to develop FCGH contents • With partners, developed Manifesto on Global Health Justice and an FCGH, laying out key principles and the case for an FCGH • Developing a “framework of a framework” to give more detail on the proposed FCGH • Draft planned for early 2013 • www.jalihealth.org

8. Support for the FCGH • Health and human rights leaders including SECTION27 (South Africa), Lawyers Collective (India), Paul Farmer • UN Secretary-General Ban Ki-moon (2011): “Let the AIDS response be a beacon of global solidarity for health as a human right and set the stage for a future United Nations framework convention on global health.” • UNAIDS: “We join others in calling for a critical debate and for unprecedented social and political mobilization towards a framework convention on global health.” Michel Sidibe and Kent Buse (2012) • UN human rights Special Rapporteurs on health, extreme poverty, water and sanitation endorsed • Representatives of 25 developing countries – members of Partners in Population and Development – call for their governments to support FCGH (November 2012).

9. Central FCGH Elements • Universal health coverage • Standards for health systems, public health interventions, underlying determinants of health • Financing framework covering domestic and global health financing • Right to health grounding, including accountability, participation, equity • Elevate health in other regimes (e.g., trade, financing, agriculture) • Alignment with national health strategies and systems • Innovative financing mechanisms • Strong mechanisms of monitoring, evaluation, and compliance • As a framework convention, anticipate protocols on specific issues (e.g., R&D, health worker migration)

10. More FCGH Possibilities • Right to health capacity building fund (to support NGOs, government institutions, and others building public understanding of and advocating for the right to health) • Global Fund for Health • Multi-sector forum with strong civil society participation to help integrate the right to health in various global health regimes • You tell us!

11. Why the FCGH?

12. Financing • Develop agreed upon domestic and international funding responsibilities that will provide sufficient, sustained, and predictable funding for global health • Establish legal norms and mechanisms to increase development partner alignment with national health plans developed through inclusive, participatory processes • Possibility of including innovative financing mechanisms and rationalizing global health financing architecture • Could include agreement on measures to increase domestic tax revenue • Strong correlation between tax revenue and development indicators • Direct taxes (e.g., income, corporate) more progressive than indirect taxes (e.g., value added tax)

13. Defining Universal Health Coverage Up • Establish guidelines on universal health coverage that define UHC up – a robust, comprehensive UHC that will not create poor care for poor people, or fail to cover essential yet more expensive health interventions (e.g., AIDS treatment) • Bring underlying determinants of health (e.g., food and nutrition, water and sanitation) within the realm of universal health coverage • Inclusive and participatory processes to translate FCGH norms to national targets and policies

14. Health and Equity • Legal framework for policies and funding to significantly close health inequities and benefit health especially of least healthy populations • Health equity • Country-specific equity targets and strategies • Prioritize and support policies and processes to meet health needs of marginalized populations • Women’s rights • Address violence against women (e.g., legal capacity-building, norm change) • Maternal and child mortality audits • Other possibilities • Require reforms of discriminatory laws that undermine health and hinder certain people from accessing health-services • Ensure universal health coverage for all immigrants (including undocumented)

15. Accountable Health Systems • Potential to build right to health accountability at all levels • Require community health accountability strategies (e.g., village health committees, community scorecards) • Build social health rights capacity (e.g., NGO capacity, media, popular education on right to health) • Strengthen national institutions (e.g., human rights commission, right to health legal training, parliamentary human rights committees) • Clearer right to health standards of international cooperation and assistance • FCGH – and so right to health – compliance • Reporting and transparency requirements • Accountability mechanisms built into FCGH (e.g., justiciability of right to health, strengthen civil society capacity) • Innovative approaches to incentives and sanctions

16. Access to Medicines and Health Workers • Protect access to medicines • Require bilateral and multilateral trade agreements to protect access to medicine • R&D • Protocol based on WHO’s Consultative Working Expert Group • Targets on public financing for R&D to address health needs in the South • Research outcomes as global public goods • Health worker migration • Build on WHO Global Code of Practice on the International Recruitment of Health Personnel

17. From Proposal to Law: Post-2015 Agenda and the FCGH

18. Integrating FCGH Principles into the Post-2015 Development Goals • Post-2015 development framework likely to set stage for health and development through 2030 • Platform for key FCGH principles and potential stepping stone to the FCGH • JALI has developed 10 principles to inform post-2015 health goal(s), building on idea of universal health coverage • Also recommendations on the process • Establish separate community/civil society committee(s) that must approve framework before UN approves • Some targets and indicators could be adapted at country level • Develop guidelines to accompany the post-2015 goals, targets, and indicators to capture critical yet difficult to measure actions

19. Post-2015 FCGH Principles (1-5) • Broadly defined universal health coverage, including underlying determinants of health (e.g., nutritious food, clean water) • “Equality through equity,” emphasizing closing health inequities, including strategies addressing marginalized populations and removing discriminatory laws • Build on current commitments • “Universal” as truly universal, leaving out no one • Continued progress, with all countries progressing towards fully realizing the right to health

20. Post-2015 FCGH Principles (6-10) • Accountability and compliance, including strategies, targets, and indicators to ensure accountability to the right to health • Inclusive, participatory processes • Incorporate a financing framework to ensure sufficient and equitable funding • Forward-looking, addressing R&D, changing circumstances, and ensuring everyone benefits of scientific advances • Health-in-all-policies, by all actors, advancing the right to health throughout the goals, national policies, and international regimes

21. Process of Establishing the FCGH • States decide to develop the treaty • Create initial treaty draft (e.g., UN working group) • Treaty negotiations (often multiple rounds of talks and broader consultations) • Treaty may change significantly from initial draft • Process often takes several years, or even longer • Often formal negotiations only among states, but precedents for civil society involvement (e.g., working groups drafting treaty, country delegations) • States adopt the treaty through chosen forum (e.g., UN, WHO) • Individual states must sign and ratify treaty before becoming fully bound by it • Ratification process varies by country • Often parliamentary approval required • Once states ratify, they are legally bound by the treaty • Varies by country and nature of treaty whether it will be “self-executing” – people can immediately enforce treaty in courts – or first require separate “implementing legislation” before courts will enforce

22. Possible Legal Pathways Towards the FCGH • UN General Assembly • Establish committee to explore possibility (and begin drafting?) an FCGH • Request member states to submit to Secretariat views on an FCGH • World Health Assembly • Request Director-General to initiate process towards an FCGH • Establish working group to negotiate and draft an FCGH • UN Human Rights Council • Human Rights Council Advisory Committee to explore or negotiate an FCGH • Outside United Nations • States can develop treaty through separate multilateral initiative, as with the Ottawa Process to develop the Mine Ban Treaty • Could still link to UN (e.g., UN endorsement, file reports with UN)

23. Before We Arrive at the FCGH….We Need You! • FCGH cannot be achieved – or effective implementation ensured – without strong civil society support, and diverse social movements mobilized around an FCGH • Participate in JALI consultations (in-person, online) and research to help develop content of the FCGH • Extensive set of research questions • JALI expects to ramp up this process in 2013 • Blogs, surveys, more • Bring your networks into these processes so FCGH can truly represent the concerns and demands of civil society and communities, especially of those whose health most suffers due to health injustice

24. FCGH Advocacy • Support FCGH principles in post-2015 development goals • Advocate with your governments to support an FCGH • Develop national and regional FCGH coalitions to feed into FCGH development and advocacy • Build support for an FCGH among your networks and institutions, as well as regional bodies (e.g., SADC, AU) • Help draw in social justice movements beyond health (e.g., sustainable development, labor) • Join the budding International Campaign for an FCGH (being developed in 2013) • Share with us your advocacy ideas!

25. For Further Information…. • www.jalihealth.org • Join the JALI listserv to stay informed of opportunities (please contact us to join) • Contacts • MayowaJoel (mayowa@africadevelopment.org), Communication for Development Centre Nigeria • Attiya Waris (attiya@uonbi.ac.ke), University of Nairobi, Kenya • Eric Friedman (eaf74@law.georgetown.edu), Georgetown University Law Center, USA