Expert Consultation on Law for Health in the Sustainable Development Goals, Manila, Philippines, 9-10 April 2018 : meeting report

9–10 April 2018 Manila, Philippines Meeting Report EXPERT CONSULTATION ON LAW FOR HEALTH IN THE SUSTAINABLE DEVELOPMENT GOALS WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC RS/2018/GE/29(PHL) English only MEETING REPORT EXPERT CONSULTATION ON LAW FOR HEALTH IN THE SUSTAINABLE DEVELOPMENT GOALS Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Manila, Philippines 9–10 April 2018 Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines September 2018 NOTE The views expressed in this report are those of the participants of the Expert Consultation on Law for Health in the Sustainable Development Goals and do not necessarily reflect the policies of the conveners. This report was prepared by the World Health Organization Regional Office for the Western Pacific for Member States in the Region and for those who participated in the Expert Consultation on Law for Health in the Sustainable Development Goals, in Manila, Philippines from 9 to 10 April 2018. CONTENTS 3 SUMMARY .................................................................................................................................................................. 1 1. INTRODUCTION ................................................................................................................................................. 2 1.1 Meeting organization .................................................................................................................................. 2 1.2 Meeting objectives ...................................................................................................................................... 3 2. PROCEEDINGS .................................................................................................................................................... 3 2.1 Opening session .......................................................................................................................................... 3 2.1.1 Opening address ....................................................................................................................................... 3 2.1.2 Presentation: The role of law in advancing health under the 2030 Agenda for Sustainable Development ............................................................................................................................................ 4 2.1.3 Programme overview and administrative announcements ....................................................................... 6 2.1.4 Discussion ................................................................................................................................................ 6 2.2 Overview of the regional action agenda ...................................................................................................... 7 2.2.1 Presentation: Introduction to the draft regional action agenda on strengthening legal frameworks for health in the SDGs ................................................................................................................................... 7 2.3 Group work ................................................................................................................................................. 8 3. CONCLUSIONS AND RECOMMENDATIONS ................................................................................................ 8 3.1 Conclusions ................................................................................................................................................. 8 3.2 Recommendations ....................................................................................................................................... 9 3.2.1 Recommendations for Member States ..................................................................................................... 9 3.2.2 Recommendations for WHO.................................................................................................................... 9 Annex 1. Timetable ..................................................................................................................................................... 10 Annex 2. List of participants ....................................................................................................................................... 12 Annex 3. Opening Address by the Regional Director ................................................................................................. 15 Annex 4. Summary of group work comments ............................................................................................................. 17 Keywords: Regional health planning, Universal coverage, Legislation as topic, Conservation of natural resources 1 SUMMARY Under the 2030 Agenda for Sustainable Development, adopted by world leaders at the United Nations in 2015, countries have committed to realizing a holistic vision for economic, environmental, political and social development through 17 interlinked and indivisible Sustainable Development Goals (SDGs). As recognized in the World Health Organization (WHO) Western Pacific regional action framework, Universal Health Coverage: Moving Towards Better Health (2015), followed by the regional action agenda, Achieving the Sustainable Development Goals in the Western Pacific (2016), legal frameworks form an essential part of efforts to advance health in the SDGs. Legal frameworks can be used to organize and manage health systems, allocate responsibilities, set standards, and authorize and constrain action, to shape markets, alert people to particular health risks, and influence social norms about behaviour. However, countries often struggle to effectively design, implement and evaluate legal interventions due to lack of evidence and policy coherence, inconsistent enforcement, and insufficient monitoring mechanisms. At the sixty-ninth session of the Regional Committee for the Western Pacific in October 2018, WHO will present a regional action agenda on strengthening legal frameworks for health in the SDGs for endorsement by Member States. To inform the development of the action agenda, an Expert Consultation on Law for Health in the SDGs was held in Manila, Philippines on 9–10 April 2018. With expert inputs from the consultation, the action agenda will be revised and discussed further with Member States through a series of virtual consultations during May 2018, then revised again and submitted as a final draft to Member States in July 2018. The experts agreed that the action agenda will provide strategic and practical guidance to Member States on how to more effectively strengthen legal frameworks for health. Pillar 1 emphasizes the fundamental functions of law for health, including cross-cutting concerns such as governance, stewardship and multisectoral coordination. Pillar 2 stresses that strengthening legal frameworks requires more skills beyond enacting a new law, and that the various steps are iterative and interlinked throughout the process. Pillar 3 describes the array of roles and responsibilities to be taken by various stakeholders and the different capacities required, with ministries of health taking the lead. Finally, the annexes to the main document provide extremely valuable information that should be further developed to better illustrate/contextualize the broader guidance. 2 1. INTRODUCTION Under the 2030 Agenda for Sustainable Development, adopted by world leaders at the United Nations in 2015, countries have committed to realizing a holistic vision for economic, environmental, political and social development through 17 interlinked and indivisible Sustainable Development Goals (SDGs). SDG 3 – “ensure healthy lives and promote well-being for all at all ages” – exclusively addresses health; however, health in the SDGs goes beyond this third goal. Universal health coverage (UHC) is a specific target under SDG 3 and also serves as a platform that brings together diverse programmes and action for health and development. As recognized in the World Health Organization (WHO) Western Pacific regional action framework, Universal Health Coverage: Moving Towards Better Health (2015), followed by the regional action agenda, Achieving the Sustainable Development Goals in the Western Pacific (2016), legal frameworks form an essential part of these challenges and underpin efforts to advance health in the SDGs. Legal frameworks affect health and its determinants in many different ways. They are an important tool that policy-makers use to organize and manage health systems. Laws codify and allocate responsibilities, set standards, and authorize and constrain action. In an era when markets influence health behaviour and access to services, law can be used to shape markets, from banning dangerous products to mandating government procurement practices that give incentives to producers to make healthier products. Passing a law can also be a good way to convey information, to alert people to particular health risks and influence social norms about behaviour. However, countries often struggle to effectively design, implement and evaluate legal interventions as part of their strategies to improve health. The development of a law may proceed in the absence of clear problem identification, evidence base and objectives, or regard for existing legal frameworks to ensure policy coherence. Beyond the legal instrument itself, enforcement can be inconsistent. Finally, without monitoring mechanisms in place, the effectiveness of specific interventions, or lack thereof, cannot be determined to inform the further strengthening of the legal framework. At the sixty-ninth session of the Regional Committee for the Western Pacific in October 2018, WHO will present a regional action agenda on strengthening legal frameworks for health in the SDGs for endorsement by Member States. To inform the development of the action agenda, an Expert Consultation on Law for Health in the SDGs was held in Manila, Philippines on 9–10 April 2018. With expert inputs from the consultation, the revised draft will subsequently be discussed with Member States through a series of virtual consultations during May 2018, then revised again and submitted as a final draft to Member States in July 2018. 1.1 Meeting organization The Expert Consultation on Law for Health in the SDGs was held in Manila, Philippines from 9 to 10 April 2018. The meeting timetable is available in Annex 1. The consultation was attended by 11 experts and five observers. The list of participants is available in Annex 2. 3 1.2 Meeting objectives The objective of the consultation was to provide guidance on the development of the technical document on law for health in the SDGs in preparation for the sixty-ninth session of the Regional Committee for the Western Pacific in October 2018, including discussing the progress and challenges in relation to countries across the Region and identifying priority areas and approaches to advance law for health in the SDGs. 2. PROCEEDINGS 2.1 Opening session 2.1.1 Opening address Dr Takeshi Kasai, Director of Programme Management, WHO Regional Office for the Western Pacific, delivered an opening address on behalf of Dr Shin Young-soo, WHO Regional Director for the Western Pacific. Dr Shin noted that WHO has long recognized the essential role of law in the promotion and protection of population health, as well as good governance of health systems. Under the SDG agenda, health impacts SDGs beyond SDG 3 and is impacted by other SDGs (as illustrated in Fig. 1). The draft action agenda envisions a contemporary approach to strengthening legal frameworks to advance health in the SDGs, with strategic guidance and practical options on priorities, processes and capacities that countries should consider. The experts invited to this consultation were recognized for their vast range of expertise and experiences in health law, and requested to support the further development of the action agenda through their insights and ideas. The transcript of the opening address is available in Annex 3. Figure 1. Health in other SDGs 4 2.1.2 Presentation: The role of law in advancing health under the 2030 Agenda for Sustainable Development Dr Vivian Lin, Director of Health Systems, WHO Regional Office for the Western Pacific, provided a presentation on law for health in the SDGs. She noted that the SDGs’ holistic vision for economic, environmental, political and social development places health firmly at the centre of the development agenda (as illustrated in Fig. 2). This brings enormous opportunity but also significant challenges: How do we ensure a continuing focus on equity in the pursuit of the SDGs? How do we balance public good against individual liberty in designing health services? How do we balance prevention and health promotion against more expensive treatments in decisions about allocating scarce resources to achieve UHC? Figure 2. SDGs, UHC and the health system HSS, health systems strengthening; SDG, Sustainable Development Goal; UHC, universal health coverage. Law is fundamental to the five key attributes of an effective health system: quality, efficiency, equity, accountability, and sustainability and resilience. Action domains under these attributes that relate closely to law include regulations and regulatory environment, system design to meet population needs, financial protection, service coverage and access, nondiscrimination, government leadership and rule of law, and public health preparedness (Fig. 3). 5 Figure 3. Health system attributes and selected actions for law Advancing UHC and the SDGs requires collaborative partnerships across sectors of government, diverse stakeholders and communities to address the many interconnected health and development challenges. Legal frameworks are vitally important as tools of cooperation and coordination. How do countries integrate law into their overall strategies for managing health systems and achieving population health and development goals? Fig. 4 illustrates the guiding questions for achieving health in the SDGs and selected actions for law. Figure 4. Guiding questions for achieving health in the SDGs and selected actions for law Countries are working to enhance the rule of law and expand the role of law in the development, implementation and evaluation of health policy to deliver safe and good-quality health services; to 6 prevent and manage public health risks, including noncommunicable diseases; and to prepare and respond to health emergencies. How to strengthen legal frameworks to advance UHC and health in the SDGs will depend on the context of the particular country. Countries in the Region are highly varied in terms of health needs and priorities, as well as in their legal systems and traditions, and political, economic, social, cultural and historical circumstances. Still, many share common challenges, including the need for a stronger evidence base, technical capacity, policy coherence, enforcement, and evaluation and monitoring to assess effectiveness and improve impact. Fig. 5 presents some examples of legal issues faced by countries supported by the Health Law and Ethics (HLE) unit of the WHO Regional Office for the Western Pacific. Figure 5. Examples of legal issues in countries supported by HLE The HLE unit was established under the Division of Health Systems in 2016 in response to the increasing demand for technical support on legislative and regulatory reforms for health. HLE works across various technical programmes throughout the Regional Office and country offices, as well as other regions and headquarters. HLE works with a broad range of stakeholders, including policy- makers and regulators in ministries of health, finance, education, and justice; local governments; parliamentarians; civil society; communities; and development partners. Core components of the HLE programme include enhancing access to research and evidence, maintaining policy surveillance, developing tools and resource materials, conducting capacity-building, building networks and partnerships, and providing direct technical support to countries. The draft action agenda—which will guide HLE and other units to better serve the Member States in strengthening legal frameworks for health—reflects the importance of health law for WHO and Member States in the Western Pacific. 2.1.3 Programme overview and administrative announcements Dr Ki-Hyun Hahm (co-responsible officer), Technical Officer, HLE, provided an overview of the programme for the expert consultation and administrative announcements. 2.1.4 Discussion All delegates introduced themselves, including highlights of their experiences in working with countries on health law. 7 2.2 Overview of the regional action agenda 2.2.1 Presentation: Introduction to the draft regional action agenda on strengthening legal frameworks for health in the SDGs Mr Luke Elich (co-responsible officer), Technical Officer, HLE, introduced the draft action agenda, including a review of the situation in the Region. He noted the diversity of legal systems and traditions, cultures, socioeconomic development, and health system maturity. For Pacific countries, challenges include out-of-date laws, legal transplantation, weak implementation and limited legal/technical capacity. Highly decentralized settings are vulnerable to fragmentation, conflict between agencies, lack of accountability, and financing issues. Transitional economies struggle with ad hoc development of laws, administrative complexity, public/private blurring, and challenges in building coherence. Advanced economies face high public expectations, the necessity for cross- sectoral policy and action, and challenges brought about by new technologies. Meanwhile, all countries are subject to ever-increasing, ever-evolving forces of change, such as demographics and epidemiological shifts, escalating costs and reductions in funding, globalization, and climate change. Fig. 6 illustrates the conceptual framework for the draft action agenda that includes objectives, priorities, processes and capacities. Figure 6. Conceptual framework for draft action agenda To advance health in the SDGs’ legal frameworks, modern laws are needed to establish health system governance and stewardship; protect rights; ensure access to affordable, safe and quality health services; prevent and manage public health risk; and promote action on social determinants of health. In many countries, however, laws are not in place or are not consistent with contemporary understanding and evidence. Protection of rights within public health legislation is a particular area in which opportunities for reform have generally not been taken up; also lacking are flexibility and alignment in responding to new and emerging public health risks. Many countries are expressing intentions to move toward health-in-all-policy approaches; however, very few countries have introduced specific legislative mechanisms to support this, such as requirements for health impact assessments. The processes involved in developing and implementing laws also need to be strengthened. This includes processes of problem definition, community and stakeholder engagement, application of relevant information and strategy development. These processes often occur simultaneously and on a continuing basis, and are affected by many technical, political and other forces. Currently in many 8 countries, processes are often short and quickly go to drafting of legislation without adequate definition of policy, generation and use of evidence, and stakeholder consultation. Quick reform using models from other countries that are copied and pasted into existing laws leads to inconsistencies within the law itself and across other laws in the statute book. Primary legislation may be passed without subsidiary legislation to enable implementation and enforcement. Furthermore, the immediate rollout of legal frameworks and ongoing administration of law are often not well planned and resourced. All stakeholders – including policy-makers, parliamentarians, regulators, civil society and communities, and academic institutions, as well as intergovernmental organizations – need to understand their roles in the development and implementation of law and be capable of discharging them. However, development of capacity in the effective development and implementation of law to advance health has not received significant attention. There is an important role for lawyers and legal expertise that needs to be developed. This role spans a broad range of areas of law, as well as different kinds of legal practice. Importantly, there is also a need to bridge the divisions between lawyers and non-lawyers. Countries and the academic community give limited attention to evaluation and research of health law, leading to a weak evidence base for the effectiveness of legal interventions, as well as other aspects of the policy development process. More transdisciplinary approaches to public health law can help break down disciplinary, cultural and resource barriers that have prevented the full recognition and optimal role of law in public health. The draft Western Pacific Regional Action Agenda on Strengthening Legal Frameworks for Health in the Sustainable Development Goals recognizes the importance of integrating the effective use of law into public health literacy and practice. It provides guidance in relation to the design of laws themselves, as well as the processes and capacities needed for their effective development, implementation and enforcement, and review. 2.3 Group work The Meeting participants were assigned to small groups and tasked to review and comment on the draft action agenda, section by section. The comments will be incorporated, as appropriate, into a revised draft of the action agenda, which will then be shared with Member States for further comments. A table summarizing the comments is available in Annex 4. 3. CONCLUSIONS AND RECOMMENDATIONS 3.1 Conclusions Whereas countries are increasingly recognizing the important role of law in health, and seeking support from WHO in health law reform, the technical document will provide strategic and practical guidance to Member States on how to more effectively strengthen legal frameworks for health. The technical document should embrace a broad definition of “law” that goes beyond legislation and regulation; for example, it should include constitutional and treaty obligations, as well as certain types of “soft law” (e.g. administrative orders, policies) that may carry the effect of law. In light of the diverse political systems, legal traditions and health needs in countries across the Region, as well as context-specific concerns (e.g. for advanced economies, decentralized settings), the 9 document should also provide a broad, nonprescriptive perspective on the priorities, processes and capacities involved. Pillar 1 (Priorities – what needs to happen) is important to emphasize the fundamental functions of law for health, including cross-cutting concerns such as governance, stewardship and multisectoral coordination. Pillar 2 (Processes – how to do it) is important to emphasize that strengthening legal frameworks requires more skills beyond enacting a new law (e.g. not just legal drafting), and that the various steps (e.g. stakeholder engagement) are iterative and interlinked throughout the process. Pillar 3 (Capacities – who is involved) is important to emphasize the array of roles and responsibilities to be undertaken by various stakeholders, and the different capacities required, with ministries of health taking the lead. The annexes to the main document provide extremely valuable information that should be further developed to better illustrate/contextualize the broader guidance (e.g. Annex 2, which maps specific potential policy options under each priority objective). 3.2 Recommendations 3.2.1 Recommendations for Member States Member States will be invited to review a revised draft of the technical document and provide their inputs via virtual consultations with the Regional Office (e.g. teleconference, videoconference, or by written comment). 3.2.2 Recommendations for WHO WHO will revise the draft technical document (version 1) by mid-May 2018 with inputs from the Expert Consultation. The revised draft (version 2) will be shared with Member States in preparation for the virtual consultations through May and June. Following the Member State consultations, the draft technical document will be further revised as a final draft (version 3) that will formally be submitted to Member States in July in advance of the session of the Regional Committee. 10 Annex 1. Timetable 08:30 – 09:00 Registration 09:00 – 10:00 Session 1 - Opening Address (5 min) by Dr Takeshi Kasai, Director of Programme Management, WHO WPRO, on behalf of Dr Shin Young-soo, WHO Regional Director for the Western Pacific - Self-introductions (20 min) by all participants - Technical Presentation: The Role of Law in Advancing Health under the 2030 Agenda for Sustainable Development - WHO WPRO Action Agenda on Strengthening Legal Frameworks for Health in the SDGs (15 min) by Dr Vivian Lin, Director of Health Systems, WHO WPRO - Programme Overview and Administrative Announcements (5 min) by Dr Ki-Hyun Hahm (Co-Responsible Officer), Technical Officer, Health Law & Ethics Unit, Division of Health Systems, WHO WPRO - Questions and Clarifications (10 min) - Group photo (5 min) 10:00 – 10:30 Tea Break 10:30 – 11:00 Session 2: Overview of Regional Action Agenda - Overview Presentation (10 min) by Mr Luke Elich (Co-Responsible Officer), Technical Officer, Health Law & Ethics Unit, Division of Health Systems, WHO WPRO - Discussion (20 min) 11:00 – 12:00 Session 3: Situation in the Region - Overview presentation: Situation in the Region (10 min) by Mr Luke Elich - Comments (20 min) - Discussion (30 min) 12:00 – 13:00 Lunch 13:00 – 15:00 Session 4: Priorities – What needs to happen? - Overview of Pillar 1 (10 min) - Group work A (60 min) - Report back and discussion (50 min) 15:00 – 15:30 Tea Break 15:30 – 17:00 Session 4: Priorities – What needs to happen? (continued) - Group work A (60 min) 11 - Report back and discussion (30 min) 17:30 – 19:00 Welcome Reception 10 (Tuesday) April 2018 08:30 – 10:15 Session 5: Processes and Capacities - Overview of Pillars 2 and 3 and intro to group work (15 min) - Group work B (sections 1–2) (45 min) - Report back and discussion (45 min) 10:15 – 10:45 Tea Break 10:45 – 12:00 Session 5: Processes and capacities (continued) - Group work C (sections 3–4) (45 min) - Report back and discussion (30 min) 12:00 – 13:30 Lunch 13:30 – 15:00 Session 6: Pillar Review and Checklist Questions to Guide Action - Introduction (5 min) - Group work D (45 min) - Report back on group D (40 min) 15:00 – 15:30 Tea Break 15:30 – 16:00 Session 7: Advocating for Action Agenda on Strengthening Legal Frameworks for Health - Introduction (5 min) - Roleplay: Elevator Pitch to the Minister of Health (25 min) 16:00 – 16:30 Session 8: Ways forward and recommendations - Conclusions and next steps (25 min) - Closing remarks (5 min) 12 Annex 2. List of participants TEMPORARY ADVISERS Ms Catherine Michele Allen Staff Attorney, National Congress, National Government Complex, Palikir, Pohnpei 96941, Federated States of Micronesia Tel. No.: +691 320 2324 / E-mail: mscathmallen@gmail.com Professor Scott Buris Professor of Law and Public Health, Beasley School of Law, Temple University, 1719 N. Broad Street, Philadelphia, Pennsylvania 19122, United States of America Tel. No.: +1 215 8709415 / E-mail: scott.burris@temple.edu Professor Calvin Ho Assistant Professor, Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Level 11, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228 Tel. No.: +65 967 38687 / E-mail: medhwlc@nus.edu.sg Dr Genevieve Ellen Howse Independent Consultant, 22 Ailsa Grove, Ivanhoe, Victoria 3079, Australia Tel. No.: +61 3902 88556 / E-mail: g.howse@howsefleminglegal.com Professor Katsuma Yasushi Professor, Graduate School of Asia-Pacific Studies, Waseda University, Nishi-Waseda Bldg. 7F, 1-21-1 Nishi Waseda, Shinjyuku-ku, Tokyo 169-0051, Japan Tel. No.: +81 3 6317 5895 / E-mail: katsuma@waseda.jp Professor Gabriel Leung Dean, Li Ka Shing Faculty of Medicine, University of Hong Kong, 21 Sassoon Road, Pokfulam, Hong Kong (SAR) Tel. No.: +852 3917 9210 / E-mail: gmleung@hku.hk Mr Jonathan Liberman Director, McCabe Centre for Law & Cancer, 615 St Kilda Road, Melbourne VIC 3004, Australia Tel. No.: +61 39514 6100 / E-mail: jonathan.liberman@cancervic.org.au Mr Ramon Navarra, Jr Director, Office of Senator Risa Hontiveros, Senate of the Philippines, GSIS Bldg., Financial Center, Diokno Boulevard, Pasay City, Australia Tel. No.: +63 917 5390719 / E-mail: rnavarrajr@gmail.com Professor Myongsei Sohn Yonsei University Health System, Rm 419, Yonsei-ro 50-1, Seodaemun-gu Seoul, Republic of Korea Tel. No.: +82 10 5396 5340 / E-mail: msohn53@yuhs.ac Professor Wang Chenguang Professor of Law, School of Law, Tsinghua University, Mingli Building, Haidan District, Beijing 100084 Tel. No.: +86 10 6277 3499 / E-mail: wcglaw@mail.tsinghua.edu.cn 13 OBSERVERS Mr David Patterson Manager/Advisor of Health Programs, International Development Law Organization, Hofweg 9E, 2511AA The Hague, Netherlands Tel. No.: +31 70 240 0869 / E-mail: dpatterson@idlo.int Ms Evita Ricafort Regional Coordinator – Asia, McCabe Centre for Law & Cancer, Manila, Philippines Tel. No.: + 63 2 6186008 / E-mail: Evita.ricafort@mccabecentre.org Ms Kathryn Johnson Human Rights and Gender Officer, HIV, Health and Development, Asia and the Pacific, United Nations Development Programme, 3F United Nations Service Building, Rajdamnern Nok Avenue, Bangkok 10200, Thailand Tel. No.: +66 2 3049100 / E-mail: kathryn.johnson@undp.org Professor So Yoon Kim Assistant Professor, WHO Collaborating Centre for Health Law & Bioethics, Asian Institute for Bioethics & Health Law, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu 120-752, Seoul, Republic of Korea Tel. No.: +82 2 2228 2532 / E-mail: syoonkim@yuhs.ac Mr Jonghyuk Lee Researcher, WHO Collaborating Centre for Health Law & Bioethics, Asian Institute for Bioethics & Health Law, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu 120-752, Seoul, Republic of Korea Tel. No.: +82 2 2228 2532 / E-mail: jonghyuk8671@gmail.com SECRETARIAT WHO – REGIONAL OFFICE FOR THE WESTERN PACIFIC P.O. Box 2932, United Nations Avenue, Ermita, 1000 Manila, Philippines Telephone: +63 2 528 8001 Website: www.wpro.who.int Dr Vivian LIN Director, Division of Health Systems E-mail: linv@who.int Dr Ki-Hyun HAHM (co-responsible officer) Technical Officer, Health Law and Ethics Unit, Division of Health Systems Tel No.: +63 2 528 9826 / E-mail: hahmk@who.int Mr Luke ELICH (co-responsible officer) Technical Officer, Health Law and Ethics Unit, Division of Health Systems Tel No.: +63 2 528 9827 / E-mail: elichl@who.int Ms Britta BAER Technical Officer, Equity and Social Determinants of Health, Division of Health Systems Tel No.: +63 2 528 9084 / E-mail: baerb@who.int 14 WHO – REGIONAL OFFICE FOR THE EASTERN MEDITERRANEAN Dr Hala ABOU-TALEB Technical Officer, Policy and Health Planning Unit, Health Systems Development Department Tel No.: +20 100 601 9084 / E-mail: aboutalebh@who.int 15 Annex 3. Opening Address by the Regional Director Ladies and gentlemen, The 2030 Agenda for Sustainable Development was adopted by world leaders at the United Nations in 2015. Through this landmark agreement, countries have committed to leaving no one behind by realizing a holistic vision for economic, environmental, political and social development through 17 interlinked and indivisible Sustainable Development Goals (SDGs). SDG 3 focuses on health. Universal health coverage – all people and communities having access to good-quality health services without financial hardship – is both a target under SDG 3 and a unifying platform for the achievement of all health-related targets across the SDGs. Other health-related SDG targets include: — nutrition in Goal 2, — gender equality in Goal 5, — clean water and sanitation in Goal 6, — waste management in Goal 11, and — climate-related hazards in Goal 13. To assist Member States, the WHO Western Pacific Region developed action frameworks for UHC in 2015 and then for the SDGs in 2016. The frameworks provide strategic guidance and practical options for countries in advancing action. Law is an integral part of these frameworks. At this expert consultation, we are now considering a draft action agenda on strengthening legal frameworks to advance health in the SDGs. Law is essential to the promotion and protection of population health, as well as good governance of health systems. Law is fundamental to the five key attributes of an effective health system: quality, efficiency, equity, accountability, and sustainability and resilience. While the SDGs emphasize working in new ways across sectors, law is instrumental to driving the whole-of-government, whole- of-society approaches called for in the SDGs. Countries are increasingly using law to support health-related policy to deliver safe and good-quality health services; to prevent and manage public health risks, including noncommunicable diseases; and to prepare and respond to health emergencies. While countries in the Region have different legal traditions, many share common challenges in health policy-making. They include the need for a stronger evidence base, technical capacity, policy coherence, enforcement, and evaluation and monitoring to assess effectiveness and improve impact. The draft action agenda envisions a contemporary approach to strengthening legal frameworks, with strategic guidance and practical options on priorities, processes and capacities that countries should consider when reforming laws for health. WHO has long recognized the importance of law in health. The health law unit works across various technical programmes throughout the regional office and country offices to assist Member States in 16 strengthening legal frameworks for health. As the demand for support continuous to grow, the draft action agenda will guide the health law unit to better serve the Member States. Many Member States are working to enhance the rule of law and expand the role of law in the development, implementation and evaluation of health policy. The draft action agenda will be presented to Member States for endorsement at the Sixty-ninth session of the Regional Committee in October. As experts invited to this consultation for your vast range of expertise and experiences in health law, your insights and ideas will prove invaluable to further inform the development of the action agenda. Thank you. 17 Annex 4. Summary of group work comments Overall structure • The five priority areas are generally alright – must be made clear that order and weight differ from country to country. • The “what” needs to be clearly linked to the “how” and the “who”. • Stronger links should be made to the objectives of the SDGs – links are not explicit. • Visualization – the circles don’t quite show the interconnections adequately. • Acknowledgement of rights – but perhaps in all sections there is a need for a people-centred approach. • Frame in terms of importance of raising health on the development agenda. • There needs to be an impetus for using framework. • Use it as a teaching tool and a persuasion tool. • Not framed as a mandate, framed softer and used enabling – synergies and sequencing. • Not quite priorities but more like action areas. • What was missing? Where is equity in these priorities? o Human rights is about the individual more than about equity. o Social determinants of health (SDH) – about multisectoral, than equity (refer to commission on social determinants) o Other cross-cutting issues? • Query on the objectives – in diagram. • Whether priorities is the right word? • Need for the wording to respond to country perspectives. • Rights and rights-based approach are key and overarching – include in narrative. • Wording matters – and think about titles. • Need stronger links with the SDGs. • Prevent and manage public health risks. • Include rights as a section on its own and mainstream it through the document. Constituting health system governance • Broaden theme to include stewardship and leadership. • Highlight importance of the subnational, particularly in some countries. • Role of consolidation and streamlining legislation – could be a good thing. • Role of parliament – oversight function. • Statutory institutions (not legal institutions). • Not limited to legislative, but include administrative means (include delegation). Promoting health through social determinants of health • Whole-of-government and whole-of-society approach. • Think about linkages with governance section. • Discussion on positives and negatives – for example, in law enforcement, where do we want them in and where do we want them out. • Not all about getting people involved. • Point in direction of implementation and enforcement. 18 Preventing and managing public health risk • Check on numbering. • Current emphasis on communicable disease risk – disentangle noncommunicable diseases. • Change focus to delivery of core public health functions – general guidance more than specific details. • Four-prong policy approach – a regulatory regime (coercive measures); financial-based (incentives/disincentives); creation of knowledge and awareness (if combined with other measures); service delivery and provision of services. • Element of authority – infrastructure – provisions will be implementable and enforceable. • Annex 2 – put detail in there. Respecting, protecting, fulfilling rights • Title – illustrate what respect, protect, and fulfil means. Use human rights language without saying human rights. • This section can be linked to “no-one left behind”. Law should protect people from discrimination. • Right to health is important – should encourage Member States to adopt. • Safeguards – informed consent, privacy, confidentiality. • Broad and linked to other priority areas – equal access to service in 1.3; working environment in SDH section (mainstreamed). • This section particularly focuses on vulnerable populations. Ensuring access to safe and quality health services • Ensuring equal access to affordable and quality health services (change title). • Regulate health-related research • Medical devices (added to organ tissues). • Useful to explain document on regulatory convergence and cooperation. • Sometimes law on confidentiality prevents research – need to balance. Other • Linkages between the sections – avoid redundancy. • Health information and health research ** Data sovereignty. • “Preventing and managing public health risk” • Instruments available beyond health in international environment should be embedded more. • Think about as core areas – consistent approach – systematic (information, financing, etc.). • Linkages between sections (potentially using examples to assist). Identification and development, overcoming barriers and driving change • Include a wedge for phase for drafting and passage – important capacity weakness in the Region. • Note that law is not the only potential outcome of the identification and development phase – maybe we don’t want a law, or want some other instrument/strategy. • Think about framework and funding for evaluation and research work to inform identification and development process. 19 • Need to include example (illustrative) – to analyse why something is happening, develop options, analyse stakeholders. Could potentially take an example through all the processes – show how it comes together. • Note everybody does this all the time. • Need to connect with real problems on the ground – how response will affect different stakeholder groups. • Could potentially simplify stakeholder groupings – community; government; parliamentarians. Potentially including academic and research community. • Consider parliamentarian staff as key stakeholder group: o Consider regional-level entry points – momentum at regional level can be picked up at country level. Common agenda regionally and sub-regionally. o Potential of surveillance – information on what other countries are doing. o For some countries, outside pressure is not so powerful. Really need to mobilize internally (e.g. China). International collaboration necessary, but internal drivers are more important. • Need processes to develop internal consensus. • Critical entry points, for example, getting into the legislative agenda. o Also subregional groupings, for example, trilateral health ministers meeting. • In remote areas, also locally driven. • Balancing the internal pressure and question-asking with access to information and options for way forward. • In parliamentary settings, can get bottom up working through representatives. In China, for example it is much more top down. • Change often comes from community and civil society. • Lots of resources on advocacy – don’t need to develop anything new – need to ensure people have access to it. • Identification and development – there’s some stuff but needs to be revised; implementation and enforcement are big gaps in resources and tools. Then the need to assess and review. • How to bring different groups together and understand each other – legal experts, with public health etc. Technical backgrounds is a key barrier to overcome. o Understanding clearly what needs to be done. o Tools and resources – for example, causal theories, training on how law works; Haden matrix – think through many options (e.g. think about implementation and enforcement; risks associated with different options). o This is not about telling people what to do, but how to adapt. • Need to draw on knowledge as well as evidence – don’t want to be an obstacle to progress. • Important to have long and considered process – can’t be short-term. Need to involve local institutions – can pair up and network. • Need to change expectations around what’s involved in these processes – ensure sufficient time frames for effective processes – generate ownership and go through processes. • Need to have clear priorities – can’t be doing a lot at once (particularly in limited settings) – do a few things well. • Things can be initiated from a broad range of places – politics change and political climates change. Coalition to defend when things go in the wrong direction; coalition to monitor, maintain engagement. 20 Implementation and enforcement • Starting point – thinking through in the design phase that what is being proposed is implementable. • Self-reporting – can’t rely on it on its own. • Set priorities for enforcement, just like setting priorities for legislation (can’t do everything at once). • There’s always a shortage of enforcement resources – potential for delegation and outsourcing of particular enforcement functions. • Empowerment of third parties – e.g. social organizations. Use their ability to provide accountability. • Different models of enforcement – not only government, top down – e.g. producers have primary responsibility (and government a check). • Meta-regulation models. • Standards, monitoring, need way to get people compliant (they can be in or out of government). • Useful to think about citizen monitors, traditional mechanisms – important role of traditional leaders (incorporate it informally into the regulatory system). • Can require agencies to establish internal compliance bodies. • Can use technology – for example, supply chain linked to compliance software – use technology to reduce opportunities to “cheat”, and create records for audit and compliance. • Don’t want to send message that government is not important – but encourage creativity and flexibility. • Primary drive for enforcement is government – but that doesn’t mean that government should have all the responsibility and work. • Want to try and avoid gaming behaviour – encourage social responsibility. • Think about how the legislative and regulatory strategies affect norms and attitudes – as a framing issue. • Causal modelling – doing legislation in waves, incremental waves. Pick losing battles – worth the fight because of media attention, etc. Get people thinking about the issue, even if only get a small win. Using incremental approach and even defeat to change norms – implementation is about getting conflict and earned media – and evidence on bad behaviour. • Use public cases to enforce – demonstration that serious…shifts attitudes (norms around being friendly – drink–driving bas social acceptance), e.g. in China. • Need enforcement regimes to be simple – least sophisticated. • Issues of whether legislation always needs to be implemented. • Incremental approaches and sunrise provisions – only come into effect when certain triggers come into effect. Evaluation and research • Evaluation critical to planning and assessment – identify implementation barriers, whether it will work, not work. • Regionally – if can show in one place – builds evidence base to advance in other countries – supports advocacy. • Not everybody needs to do the same thing – work sub-regionally and share information and functions. Work with comparable neighbours. 21 • When thinking about causal thinking, think about important things to monitor and evaluate – need to identify a couple of things that can measure – develop and evaluation plan. • Need support for local academics – funding and technical. • Need to identify priorities for evaluation and research – role of regional bodies and others in doing comparative work. • To do research, need suitable data; resources to take that data and do the analysis. • Need to grapple with political obstacle to appetite for research findings – potentially negative coverage. • Try to identify really low technology, using community groups and traditional groups – developing ownership. • Use participatory techniques – together with community. • Publishing information – domestically and regionally – creates soft pressure. (Link to implementation and enforcement.) Use of technology to support. • Perhaps monitoring and evaluation instead of evaluation and research. • Need for transparency and accessibility in terms of information. • Discussion on how to know if strengthening legal frameworks – what does success look like? Other • Some guidance on what good governance can look like – statements of principle – detail. For example, requirements for judicial review. • Some requirements that can be provided in relation to the law itself. • Creating norms and standards about how to approach the SDG goals – creating a transnational movement. • Areas of UHC that we may want to enshrine in legislation. Making national commitment in legislation, and generating demand. • Long-term plan – check progress, checkpoints. Can create forum in each country – institution with responsibility. • Engaging successful with political process – gets derailed all the time in spite of good process. Have to think about the politics and have to make arguments and engage in ways that fit into other processes and drivers. Need to be attractive politically and process. • All countries in the Region are using law effectively to advance health and development to meet their objectives. • Identify international obligations. • Identify some key interventions – “best buys”. • Think about institutional arrangements in relation to implementation – conflicts of interest, etc. – in terms of health system institutions. • Important dimension of self-accountability of public health advocates – part of that is personal and professional ethics – more fundamental than process (process doesn’t always lead to outcome). • Example of participants in law and obesity training -– different ways in which change happens. • The process is an ongoing process – continuing cycle – of evaluation methods and cycles. • Rigour around evaluation and standards – allow linkages. 22 Checklists • Checklist questions can be used to tie the pillars together. • Question about existing capacity, aligned to development, implementation strategies. • Plans for developing capacity, how to identify priorities for capacity development. • Access to existing tools, resources, programmes and mechanisms. • How these fit in with approaches to cooperation – piggy-backing on other countries (required capacity to cooperate and reference effectively) (can’t be limited to country by country) – questions on how these are being set. • Where is there expertise that is available (for example, across government) – not only what is currently known (enabler and constraint). • Role of service providers – critical in terms of implementation and monitoring and evaluation. • Build specific competencies on regulation and access to training programmes. • A lot of regulatory expertise required – not unique to health. • Reality of regulatory capture for some countries (a lot of expertise in the private sector – capture the expertise and power imbalance). • Regarding the bullet point on policy-makers familiar with legal tools – not realistic to expect of policy-makers; we can focus on how to build bridges and trust between fields of expertise – we have to institutionalize. • You know what don’t know; know where to go if you don’t know. • Potential of expert committees – bring disciplines together – link into the process. • Capacity of law as a system – needs to be coherent, systematic, etc. Consistently enforced among institutions that are working on local levels or specialized levels; this would include improving intergovernmental committees. • Institutions connected (capacity to plan). • Role of WHO in providing norms and standards. • Capacity of service providers in relation to legal issues – cross over between health and legal issues/pathways. • Medical dispute settlement capacity; reduce conflicts. www.wpro.who.int