By Katy Ramsey
The Global Alliance for Women's Health (GAWH)
On 10 July 2009, the President of the United Nations Economic and Social Council (ECOSOC) submitted the Ministerial Declaration of the 2009 High-level Segment Annual Ministerial Review (AMR). The declaration is a non-binding document but can be used as persuasive authority for ECOSOC member states and other UN bodies. It is the product of negotiations among Member States that began in New York in June 2009 and culminated at the Annual Ministerial Review in Geneva, Switzerland in July 2009.
The Global Alliance for Women's Health, Inc. (GAWH), a non-governmental organization (NGO) in special consultative status with ECOSOC, has advocated for women's health policy at the UN level since 1994. In 2003, GAWH developed a campaign to raise awareness about diabetes and other non-communicable diseases (NCDs) and their particular impact on women. As part of this campaign, GAWH facilitated two caucuses: the Council on Gender-based Health to the United Nations and the Friends of the UN Diabetes Resolution (FUNDR). Both caucuses are public-private partnerships chaired by Member States and comprised mainly of Member State delegates. GAWH is the secretariat organization for both groups.
In anticipation of the Ministerial Declaration negotiations, GAWH hosted a joint meeting of both caucuses on 9 June 2009 at the UN Headquarters in New York. GAWH distributed a proposed ECOSOC intervention statement to the meeting attendees, calling for the inclusion of specific provisions in the declaration.1 This intervention emphasized diabetes in the developing world as not just a health problem, but one that has political, economic, and development consequences. Additionally, the intervention called attention to the special impact that the disease has on women both during pregnancy and throughout the lifespan. Furthermore, it urged Member States to push for policies that reflect the different needs men and women have with regard to diabetes and to consider the social determinants that contribute to those differences. It also asked Member States to be mindful of Millennium Development Goals (MDGs) 3 and 5: promoting gender equality and empowering women and improving maternal health.
This report will analyze the extent to which those provisions were realized in the Ministerial Declaration, the impact of GAWH's advocacy on those provisions, and the willingness of delegates to push for their inclusion in the declaration. It will also explore ways to continue and expand GAWH's advocacy in the future.
II. The Evolution of the Declaration
The process of creating a declaration begins before any written draft is produced. Prior to the release of a preliminary draft, ECOSOC Member States are consulted by the secretariat and asked for their input on what elements should be included in the declaration. These "informal consultations" usually determine which broad elements will be included in the declaration. Once the first draft has been released by the secretariat, it is difficult for Member States to push for the inclusion of any new elements absent from the first draft. Therefore, subsequent negotiations among member states consist mostly of adjusting and adapting the included elements.
This section explores the provisions in the various drafts of the Ministerial Declaration that relate to NCDs, diabetes, and gender-based health, and follows the path of negotiations as demonstrated by the changes in the language and placement of paragraphs from draft to draft.
The 5 June 2009 draft of the Ministerial Declaration, the earliest version available, contains 38 paragraphs. This draft was released before GAWH's intervention statement was distributed to the Member States at the joint meeting. Paragraph 29 of this draft is devoted to NCDs, but there is no specific reference to diabetes. The language of this paragraph recognizes that NCDs place a greater burden on the social and economic sectors and development. However, the paragraph is broad and does not discuss the different effects NCDs have on men and women. Additionally, the placement of this paragraph at the end of the document is problematic, as it appears to deemphasize the importance of NCDs by not making it a more prominent part of the declaration.
There is very little language relating to women or gender-based health in the other paragraphs of this draft. In Paragraph 31, the draft mentions MDGs 4 and 5, and "express[es] concern on the lack of progress" made on those goals and calls for action to prevent maternal death. Paragraph 33 seeks to "promote gender equality and empowerment of women" and also calls for "equal access of women and girls to education, basic services, economic opportunities and decision-making at all levels." However, there are very few specific recommendations and no substantive mention of women's health outside of the reproductive years. Paragraph 8 "recognize[s] that social determinants play a central role in health outcomes and call[s] for action to address the underlying causes of inequities." The 2009 World Health Assembly (WHA) in Geneva passed a resolution titled, "Reducing health inequities through action on the social determinants of health." 3 Therefore, Paragraph 8 reaffirms the delegates' recognition of the link between social determinants of health and inequities in health status.
B. 20 June 2009 Draft 4
The 20 June 2009 draft of the Ministerial Declaration was produced after the joint meeting hosted by GAWH and the distribution of the GAWH intervention statement. This draft, the longest of any of the drafts, reflects negotiations that took place in New York. There are alternate versions of many of the paragraphs; it appears that at this stage of negotiations, Member States pushed for the inclusion of more specific provisions, including provisions relating to NCDs, diabetes, and social determinants of health.
In this draft, the NCD paragraph remains number 29 of 38. From the annotations in this draft, the European Union wanted to include mental disorders as part of this paragraph. Apart from that, the paragraph remains substantially similar to the one from the 5 June draft. The 20 June draft includes two alternative proposals to Paragraph 29, one of which, Paragraph 29bis, was proposed by the G77 and explicitly states, "[D]iabetes is a chronic, debilitating, and costly disease associated with severe complications, that poses serious challenges to the achievement of internationally agreed development goals, including the Millennium Development Goals." This wording is much stronger than in the previous draft of the declaration and aligns with the language used by GAWH in the intervention statement. The other alternative proposal deals with clean drinking water, not NCDs.
The paragraphs relating to gender-based health, MDGs 4 and 5, and social determinants of health were also revised in this draft. The most substantial change was also proposed by the G77. Paragraph 9(bis) explicitly calls for "[i]ncreased commitment to address the problem of malaria and diabetes during pregnancy; a condition that impairs maternal health, and which can negatively affect their offspring." [Emphasis added.] This language emphasizes the unique impact that diabetes has on women and links diabetes to other important women's health issues. It also draws attention to NCDs in this document outside of the NCD paragraph itself.
Two paragraphs, Paragraphs 10 alt and 10 alt alt, call for "gender-sensitive mulitsectoral health policies and programmes," in place of simply "multisectoral health policies and programmes." This indicates thinking about gender-based health, although the wording stops short of calling for disaggregation of data between men and women. MDGs 4 and 5 remained in Paragraph 31 and the wording of the paragraph is substantially similar to the wording of Paragraph 31 in the 5 June draft. Paragraph 8 again contains language about social determinants of health. The four variations of the paragraph in this draft are more specific with regard to what the social determinants are; however, the ways that social determinants contribute to health status are not specified.
C. 3 July 2009 Draft 5
The language about NCDs and gender-based health that appears in the 3 July draft was agreed upon at that time and remained the same until the final version of the declaration. The placement of those paragraphs, however, had not yet been finalized. Delegates involved in the negotiation process confirmed that the NCD language was decided upon before their arrival in Geneva.
In this draft, the G77 submitted a "restructuring proposal," which lays out two lengthy paragraphs; one deals with communicable diseases and the other with non-communicable diseases. The NCD paragraph emphasizes again that NCDs carry a "heavy burden on society with serious social and economic consequences." Not only does it mention diabetes and other NCDs in the paragraph, it also contains a subpoint focusing specifically on diabetes. Subpoint (b) provides that Member States "[r]ecognize that diabetes is a chronic, debilitating and costly disease associated with severe complications." The language is almost identical to that included in the 20 June draft. Its specificity regarding diabetes represents the advocacy efforts of the G77 nations, many of whom are involved in the Council on Gender-based Health and FUNDR.
The paragraph on MDGs 4 and 5 and empowerment of women is moved up to Paragraph 9 of 36 in this draft. Although the language in Paragraph 9bis was expanded greatly from previous drafts and is much more specific with regard to "improving maternal and child health," there is no language about NCDs. The provision from the previous draft about diabetes and pregnancy was dropped from this version. However, the fact that the language was included in a previous draft can be viewed as a positive indication that delegates regard these subtle issues as important and that they can evolve into major issues in the future. Paragraph 9bis, which is marked as "agreed" in this draft, has several subpoints. Paragraph 9bis(c), deals with child health and lists specific causes of child mortality, but does not include diabetes or any other NCDs.
Paragraph 10 in this draft carries over the language from the 20 June draft of "gender-sensitive multisectoral health policies and programmes." It appears that this language was still under negotiation in this draft because it is not marked as "agreed."
D. 5 July 2009 Draft 6
As stated, the 5 July draft contains the same NCD language as the 3 July draft. However, the paragraph was moved up to 16 of 43, which puts it in a much more prominent place in the declaration. According to people with knowledge of the negotiations, by this point, the provisions still at issue among the delegates were those relating to reproductive health and intellectual property rights. The "gender-sensitive mulitsectoral health policies and programmes" language was moved to Paragraph 12, and appears not to be finalized yet.
E. Final Draft 7
In the final draft of the Ministerial Declaration, released on 10 July 2009, the NCD language remained the same. The paragraph ultimately ended up as number 18 of 44. This is a significant improvement over its original placement at 29 as it reflects an agreement among the delegates that NCDs deserve a more prominent location within the document. The paragraph on social determinants of health was moved to number 10, and the paragraph on MDGs 4 and 5 was moved to number 15. Paragraph 13 contains the language about equitable access for women and girls to education and health services. "Gender-sensitive multisectoral health policies and programmes" ended up in Paragraph 14. The fact that all of these concepts appear in the first half of the document is promising because it reflects a consensus that NCDs, women's health, and gender-based health are important issues.
III. The Impact of GAWH's Advocacy
During conversations with ECOSOC Member States, delegates at the Third Committee level 8 stated that GAWH's advocacy has contributed significantly to Member States' increased awareness about the problem of NCDs, specifically diabetes, in developing countries, as well as the unique ways that NCDs affect women compared to men. According to these delegates, NCDs and diabetes would not have advanced as far as they have without GAWH's advocacy work. One of the important changes in recent years among ECOSOC Member States is that the United States now supports many NCD initiatives. Countries following the lead of the U.S. interpret that support as an indication that there is a consensus on NCDs, and are thus more likely to support stronger language. It is also important that so many developing countries, especially African nations, are involved in the Council on Gender-based Health and FUNDR and advocate for language like that in the Ministerial Declaration, because NCDs have a huge impact on their populations.
Many developing countries rely heavily on UN documents in formulating domestic health policy. Therefore, the language included in documents like the Ministerial Declaration is influential both at the UN and at the national level. The fact that it is now broadly recognized among Member States that NCDs have a significant impact on development and other non-health sectors such as politics and economics and should be dealt with accordingly.
Delegates also explained that one of the challenges for advancing a specific issue in Ministerial Declarations is that Member States can be reluctant to include very specific language about a particular issue. Until specific language appears in other UN documents, preferably something coming from the Secretary General, diplomats might not be willing to support specificity in lower-level documents like Ministerial Declarations. Therefore, the fact that the diplomats who do support specific language on NCDs were able to successfully advocate for its inclusion in this Ministerial Declaration can be considered a success.
IV. Future Actions
The momentum from the accomplishment of getting diabetes-specific language into the 2009 Ministerial Declaration must be carried forward in order to broaden awareness of NCDs and diabetes and their impact on women's health, both among other ECOSOC member states and in the UN beyond ECOSOC. GAWH can consider advocating to both ECOSOC and non-ECOSOC Member States in advance of the September General Assembly in order to keep NCDs and their special impact on women on their agendas. GAWH can also advocate at the UN beyond ECOSOC and make connections at UN agencies such as UNICEF, UNDP, and UNFPA to partner to address diabetes as a women's issue and a development issue. In order to maintain GAWH's successes, the organization can attempt to permeate the women's agenda, gender mainstreaming, and other areas with health implications that people might not be thinking about. GAWH could also consider going beyond the UN to the Organization of American States (OAS), based in Washington, D.C., and use the same strategies of education and awareness to delegates at that level that have been successful at the UN.
GAWH has been advocating for greater recognition of NCDs and diabetes and their impact on women at the UN level since 2003. The 2009 Ministerial Declaration from the ECOSOC Annual Ministerial Review includes strong language about the need to address NCDs and diabetes not only as a health issue, but also as an economic, social, and development issue. The evolution of the declaration from its first draft to final form reflects a negotiation process among member states that began in New York, prior to the High-level Segment in Geneva.
The inclusion of specific language about NCDs and diabetes in the Ministerial Declaration indicates that Member States now accept these issues as urgent problems that must be addressed through strong language in documents like the Ministerial Declaration. Additionally, it is encouraging to groups like the G77 propose provisions like the reference to diabetes and pregnancy in the 20 June 2009 draft. Although that wording was ultimately not included in the final draft, it indicates that there is awareness among the Member States about the impact of diabetes and other NCDs on maternal health. It will allow for GAWH's continued and increased advocacy on these issues; GAWH can try to reassert this concept in many ways so that it becomes acceptable. According to delegates involved in the negotiation process, GAWH's consistent advocacy has contributed significantly to the increased awareness of these issues among Member States and has led to their inclusion in the Ministerial Declaration. This, in turn, can pave the way for wider advocacy efforts in the future, both at the UN level and beyond.
Appendix A—Draft Intervention Statement, submitted by the Global Alliance for Women's Health, 4 June 2009
Appendix B—Selected Provisions from the Draft Ministerial Declaration: Implementing the internationally agreed goals and commitments in regard to public health, 5 June 2009
Appendix C—Selected provisions from the Draft Ministerial Declaration, 20 June 2009
Appendix D—Selected Provisions from the Draft Ministerial Declaration, 3 July 2009
Appendix E—Selected Provisions from the Draft Ministerial Declaration, 5 July 2009
Appendix F—Selected Provisions from the Final Draft Ministerial Declaration, 10 July 2009
1 See Appendix A, Draft Intervention Statement, June 4, 2009.
2 See Appendix B, Selected Provisions from the Draft Ministerial Declaration, June 5, 2009.
4 See Appendix C, Draft Ministerial Declaration, June 20, 2009.
5 See Appendix D, Draft Ministerial Declaration, July 3, 2009.
6 See Appendix E, Draft Ministerial Declaration, July 5, 2009.
7 See Appendix F, Draft Ministerial Declaration, July 10, 2009.
8 The Third Committee is one of six main General Assembly committees, and deals with Social, Humanitarian, and Cultural Affairs. See United Nations General Assembly, Social, Humanitarian & Cultural Third Committee.