Community Accountability in the context of HSRs Implications for SRH Services

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Community Accountability in the context of HSRs
Implications for SRH Services

• Ranjani.K.Murthy

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Objectives

• At the end of the session the participants would
  be familiar with
• The understanding of health accountability to
  community underpinning World Bank initiated HSRs
  and rights based groups.
• The mechanisms and to what extent marginalised
  people/women hold accountable health policy,
  manager, providers within and outside HSRs in
  Asia
• How far the community accountability strategies
  have strengthened provision of SRH services
• How far the assumption that financial
  contributions, community participation, and
  community health structures have strengthened
  health/SRH accountability are valid
• What can be done to strengthen SRH service
  accountability further in the context of reforms
  and outside

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Contrasting perspectives on Community
participation (CP)

• Alternative discourses
• 1960s Failure of top down state led economic
  growth, state to further basic needs through CP
• Alma Ata Model of PHC, implemented through
  community shaping health services
• Cairo-1994 CP as central to furthering
  reproductive and sexual rights
• Late 1990s Rights of citizens to participate

• Neo liberal
• CP as part of neo-liberal thinking on cutting
  back role of state, and market led economic
  growth
• 50 HSRs CP as means of raising resources,
  outreach, maintenance of infrastructure

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Community Accountability

• Alternative perspective
• Expand engagement of citizens in policy
  formulation, planning monitoring
• Expand responsiveness of government
• Expand answerability of government and private
  sector to citizens
• Enforce penalties when not accountable
• Sees vibrant democracy as prerequisite

• Neo liberal
• Privatization/competition
• Financial contribution by clients, community
  voice, decentralization, community health
  structures,
• Co-production of services
• Views that accountability can be added on through
  reforms irrespective of contexts

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Accountability Lower to higher order of
accountability to communities
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Definition of accountability

• Accountability refers to whether and how power
  holders at different levels engage with demands
  from other parties, respond to them, justify
  their decisions and actions, and are sanctioned
  for violation of rules to implement decisions.
• Key questions
• Who is accountable?
• To whom?
• With regard to what?
• When?
• How is accountability operationalised?
• What is the outcome of accountability processes?

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Context into which community health
accountability is being introduced/takes place

• Varying history and vibrancy of democracy
• IN some countries in the context of devolution
• Varying levels of poverty and gender inequalities
• Varying health budgets, expenditure and financing
  
• Varying SRH policies and legislation

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Strategies for strengthening community health
accountability

• Within reforms
• Involving community representatives and health
  groups in planning health sector reform projects,
  health sector wide approaches, poverty reduction
  strategy papers.
• Involving community representatives and health
  groups in community level and hospital level
  health structures (health committees, health
  boards, hospital boards etc.)
• Strengthening professional councils and their
  ability to press for accountability
• Promoting community health financing for
  strengthening health accountability
• Introducing health accountability tools like
  maternal mortality audit, provider report cards,
  patient rights charters,

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• Outside reforms
• Using progressive legislation on right of
  citizens to participation, public interest
  litigation, and right to information for
  promoting health accountability.
• Using international human rights instruments,
  agreements reached in gender/health specific
  conventions, MDGs and other targets for pressing
  for health accountability,
• Demanding gender sensitive health legislation,
  policies, programmes and budgets for furthering
  health accountability
• Monitoring implementation of progressive health
  legislation, policies, budgets and programmes.
  

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Community health accountability strategies in
HSRs in India
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Continued
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Lessons

• General lessons
• Accountability backed by legislation
• Ratification of human rights instruments,
  optional protocol helps
• Regional human rights courts helps
• Rights based NGO involvement
• Capacity building
• Resources
• Can backfire- think through all consequences
• Collect evidence
• Democracy
• Keep health professionals out
• SRH
• Capacity building on SRH
• International and national Gender experts
• Appropriate gender human rights instruments
• Sound SRH policy seems important for what can be
  achieved at lower levels
• SRH indicators for monitoring.
• Giving prefernece to poor and women in community
  grups

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Key findings Community accountability in HSRs

• Of 44 World Bank initiated HSRs (1990s/early
  2000s) in 33 developing countries, 28 include a
  component of community participation or
  accountability
• Actual reforms have adopted the following
  strategies uniformly across regions
• community health structures
• District health structures ,
• - community financing
• strengthening devolution or de-concentration
• A few reform
• Stakeholder participation in policy
• Strengthening professional associations ,
• Maternal death audits
• Client regulation-promoting patient rights
  charters
• government regulation-superintendence

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Community accountability in HSRs continued

• More examples of accountability at service
  delivery/programme management level, than policy
  level, i.e furthering managerial than political
  accountability
• Community means clients, or local community as
  far as community health structures go, and NGOs,
  women's health groups as far as policy goes
• Community participation in HSRs has remained at
  the level of consultation
• Controversial health issues kept out of agenda
  budget allocation to health, between rural and
  urban areas, user fee exemptions, rights to
  health
• Only 45 of 44 HSRs in Asia have prioritised
  at-least one SRH service, and only 25 beyond FP
  and MCH

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Community accountability in HSRs continued

• Few studies on SRH impact of community
  accountability in reform contexts.
• Available evidence suggests that
• Controversial SRH services have been kept out or
  rejected when brought into policy table e.g.
  services pertaining to violence, abortion
  services,
• SRH needs of certain groups not addressed
  adolescents, single women outside marriage,
  elderly, male RH needs, transgender
• Low priority SRH services not addressed
  reproductive cancers, infertility treatment

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Community accountability outside HSRs

• Community health accountability strategies more
  diverse
• Using accountability legislation Right to
  participation, Right to information, public
  interest legislation, patient rights bill,
  medical ethics
• Using human rights instruments
• Policy influencing, budget allocation and
  programme monitoring
• Citizens report cards
• Mobile Ombudsman Centres run by government
• Public hearings around health situation,
  implementation of policies and expenditure
• More context specific- diverse across countries
• If happening in invited spaces level of
  participation and outcomes only slightly better
  than in HSRs,

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Where in demanded spaces

• Financial contribution by client as a strategy
  for strengthening community accountability has
  never been demanded
• Higher level of community accountability, where
  marginalised communities and their
  representatives set agenda
• More examples of policy level and legislation
  influence
• Have raised controversial health budget
  allocation to health, different components and
  levels of health
• Have been effective at protecting SR rights,
  putting a stop to violation of SR by the
  government, and implementation of progressive
  policies and legislation
• But have been less effective at ensuring that
  controversial services, new SRH services, and new
  groups are actually provided.
• Issues of lack of representation of marginalised,
  institutionalisation, up scaling and reactiveness
  remain
• Democracy and vibrancy of movements, independent
  judiciary, good health system, and investment in
  capacity building seems pr-requisites

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Factors that influence the impact of
accountability strategies on SRH services

• The legal, policy, programme environment
  pertaining to SRH
• The broader economic, political and cultural
  milieu
• The health budget and institutional context
• The strategizing skills of civil society
  organisations
• The SRH sensitivity and competence of different
  stakeholders
• Need to choose according to context

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Key Discussion points

• Can HSRs promote community accountability in non
  democratic spaces, inadequate budgets, weak
  policy/legislation on SRH, lack of independent
  judiciary?
• Can HSRs promote accountability, when other
  elements of reforms are being initiated?
• Without investment in capacity building by the
  state can community accountability happen and
  strengthen SRH service ?
• Being aware of, and countering, the negative
  consequences

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Advocacy agendas

• Advocate accountability legislation national
  and signing of international ones (including
  optional protocols without reservation)
• Advocate health accountabilty legislation,
  policies (from policy to local level)- with
  budget
• Influence health/SRH legislation, health
  financing, health budgets, and allocation across
  levels and concerns from outside
• Broaden space for democracy, promote independent
  courts to function and promote devolution of
  powers
• Advocate that community contributions does not
  automatic promote accountability
• Broaden tools and strategies for public sector
  accountability, and also use them for enforcing
  accountability of the private health sector

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Advocacy agendas

• Engage with HSRs from inside
• shape reforms themselves (priority setting,
  financing, model of decentralization),
• push reforms to further a policy on community
  accountability at national, provincial, district
  and lower levels
• Promote innovative accountability strategies
  which are common outside reforms (both for
  public, private, ppis)
• Promote participation contracts between WB,
  government and CSOs
• Budget for capacity building of civil society
  actors

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Research

• Context specific analysis of community
  accountability within and outside reforms, and
  their impact, and how the other elements of HSRs
  in that specific country interact/influence
  community accountability outcomes (with respect
  to SRH services)
• To document and learn from successful
  experiences in influencing HSRs from inside,
• To document and learn experiences from
  demanded accountability to increase health
  budgets, budget allocation to different levels,
  to different health/SRH services

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Capacity building

• Sensitise national governments, aid agencies,
  specialists working on HSRs on community
  accountability discourses and practices in HSRs
  and outside, and their implications for SRH
  services
• Build capacity of NGOs, consumer groups,
  professional associations, consumer courts, trade
  unions, judiciary, government health
  superintendents on above
• In countries undergoing devolution to build
  capacity through NGOs of marginalised to enter
  these bodies, and sensitise elected leaders on
  SRH issues. Similarly with respect to community
  health structures and hospital boards