Towards Health Equity Through a Framework Convention on

Global HealthAttiya Waris

Member, JALI Steering CommitteeSenior Lecturer, School of Law, University of Nairobi

IHP+ Civil Society Consultative Group Meeting

December 10-11, 2012, Nairobi, Kenya

OverviewWhat is the Framework Convention on Global

Health (FCGH)?Why an FCGH?The FCGH, from proposal to law

Post-2015 development agendaTowards the FCGH itself

A Framework Convention on Global Health: The Basics

Background to the FCGH: Persisting Health Inequities and Challenges

Health inequitiesLife expectancy in Sub-Saharan Africa (2011): 54

yearsLife expectancy in high-income countries (2008): 80

yearsContinued and emerging global health challengesPressures requiring global response

Growing but insufficient fundingHealth worker migrationPopulation growthTrade and intellectual property (access to medicines)Global industry (e.g., tobacco, “big food”)

Background to the FCGH: Global Response Required and PossiblePower 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 healthResponsibilities lack precision, especially

global responsibilities

Framework Convention ApproachTherefore, 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 approachInitial 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

Joint Action and Learning Initiative on National and Global Responsibilities for Health (JALI)

In response, coalition forms JALIWhat 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 contentsWith partners, developed Manifesto on Global Health Justice and

an FCGH, laying out key principles and the case for an FCGHDeveloping a “framework of a framework” to give more detail

on the proposed FCGHDraft planned for early 2013

www.jalihealth.org

Support for the FCGHHealth and human rights leaders including SECTION27 (South

Africa), Lawyers Collective (India), Paul FarmerUN 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).

Central FCGH ElementsUniversal 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 systemsInnovative financing mechanismsStrong mechanisms of monitoring, evaluation, and complianceAs a framework convention, anticipate protocols on specific

issues (e.g., R&D, health worker migration)

More FCGH PossibilitiesRight 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 HealthMulti-sector forum with strong civil society

participation to help integrate the right to health in various global health regimes

You tell us!

Why the FCGH?

FinancingDevelop 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 revenueStrong correlation between tax revenue and development

indicatorsDirect taxes (e.g., income, corporate) more progressive than

indirect taxes (e.g., value added tax)

Defining Universal Health Coverage UpEstablish 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

Health and EquityLegal 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 populationsWomen’s rights

Address violence against women (e.g., legal capacity-building, norm change)

Maternal and child mortality auditsOther 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)

Accountable Health SystemsPotential 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 requirementsAccountability mechanisms built into FCGH (e.g., justiciability of

right to health, strengthen civil society capacity)Innovative approaches to incentives and sanctions

Access to Medicines and Health WorkersProtect access to medicines

Require bilateral and multilateral trade agreements to protect access to medicine

R&DProtocol based on WHO’s Consultative Working

Expert GroupTargets on public financing for R&D to address

health needs in the SouthResearch outcomes as global public goods

Health worker migrationBuild on WHO Global Code of Practice on the

International Recruitment of Health Personnel

From Proposal to Law: Post-2015 Agenda and the

FCGH

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 processEstablish separate community/civil society committee(s) that

must approve framework before UN approvesSome targets and indicators could be adapted at country levelDevelop guidelines to accompany the post-2015 goals, targets,

and indicators to capture critical yet difficult to measure actions

Post-2015 FCGH Principles (1-5)1) Broadly defined universal health coverage,

including underlying determinants of health (e.g., nutritious food, clean water)

2) “Equality through equity,” emphasizing closing health inequities, including strategies addressing marginalized populations and removing discriminatory laws

3) Build on current commitments4) “Universal” as truly universal, leaving out no one 5) Continued progress, with all countries progressing

towards fully realizing the right to health

Post-2015 FCGH Principles (6-10)6) Accountability and compliance, including

strategies, targets, and indicators to ensure accountability to the right to health

7) Inclusive, participatory processes8) Incorporate a financing framework to ensure

sufficient and equitable funding 9) Forward-looking, addressing R&D, changing

circumstances, and ensuring everyone benefits of scientific advances

10)Health-in-all-policies, by all actors, advancing the right to health throughout the goals, national policies, and international regimes

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

Possible Legal Pathways Towards the FCGHUN General Assembly

Establish committee to explore possibility (and begin drafting?) an FCGH

Request member states to submit to Secretariat views on an FCGHWorld Health Assembly

Request Director-General to initiate process towards an FCGHEstablish working group to negotiate and draft an FCGH

UN Human Rights CouncilHuman Rights Council Advisory Committee to explore or negotiate

an FCGHOutside 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)

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 FCGHExtensive set of research questionsJALI expects to ramp up this process in 2013

Blogs, surveys, moreBring 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

FCGH AdvocacySupport FCGH principles in post-2015 development

goalsAdvocate with your governments to support an FCGHDevelop national and regional FCGH coalitions to feed

into FCGH development and advocacyBuild 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!

For Further Information….www.jalihealth.orgJoin the JALI listserv to stay informed of

opportunities (please contact us to join)Contacts

Mayowa Joel (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