Keeping people at the center of accountability for health: 365 days of grantmaking

White Ribbon Alliance
A woman participates in the White Ribbon Alliance's "What Women Want" campaign in Nigeria. Photo credit: White Ribbon Alliance

Read this post in French here.

Universal Health Coverage (UHC) Day is just around the corner. On December 12, people around the world will rally for every person—no matter who they are or where they live—to get the health care they need without facing financial hardship. A year ago, I offered some ideas for funders to support UHC, including:

  • getting resources for awareness raising and advocacy campaigns to the country level where they are needed most, and
  • ensuring that the people who are most affected yet least heard from are able to participate in deliberations about UHC.

These ideas remain important and have informed our grantmaking over the past 12 months.

Why people’s participation and accountability are important for UHC

In the lead up to the High-Level Panel meeting for UHC, I suggested that failing to involve people in decision-making and oversight could imperil the successful roll-out of universal health care (UHC) policies and programs. Simply put, ensuring that all people are informed of their health rights, have a voice in shaping choices and tradeoffs, and are able to provide feedback about their experiences at health facilities is the smart thing to do.

Since we launched our Service Delivery Monitoring sub-strategy in 2018, the field of Transparency, Participation and Accountability has continued to evolve its understanding of the potential and challenges of social accountability. Specifically, we’ve learned that pairing people’s access to information along with facilitated, safe and inclusive spaces to channel feedback to authorities (aka constructive engagement) can lead to improvements in service quality.  We’ve also learned that the more successful social accountability programs do their homework. They take the time to understand how service delivery is governed and resourced, and astutely navigate local politics, which then tends to produce actions that lead to service improvements. Recent examples from Uttar Pradesh, India and Indonesia demonstrate this potential. We’ve kept these lessons in mind as we looked for opportunities to support social accountability for UHC.

Our grantmaking over the past year

“Everyone in this day and age wants data and evidence. The extent to which we’re able to put evidence on the table, that’s been the game-changer.”  Abigail Dzimadzi, former director of the Malawi Network of AIDS Service Organizations (MANASO)

Over the past year, we’ve made four grants totaling close to $4.2 million that focus on initiatives for putting people at the center of accountability for better health in eight countries. All are early stage experiments and we look forward to working with our partners flexibly to support the adaption and learning that will be a necessary ingredient for success.

Follow the money

Population Action International (PAI) along with national civil society partners are working with experts in public financial management to track whether the money promised for family planning services and supplies gets to health facilities and is used well. These national civil society organizations are using public finance data to hold governments to account to meet the commitments they have made to steadily increase domestic spending for sexual and reproductive health services.

PAI and its partners have already achieved early wins. Abigail Dzimadzi, formerly of Malawi Network of AIDS Service Organizations (MANASO), described the difference the use of public finance data has made in their advocacy campaigns:

“Expenditure on the family planning commodities budget line was below 50% prior to the [family planning expenditure tracking] project. But in the 2017/18 [budget] cycle, the expenditure rose to 86%. A lot of people didn’t know that after the money is allocated, it doesn’t get spent.”

PAI’s partners and the countries where they are working are: SOS Jeunesse et Défis and Centre pour la Gouvernance Démocratique (Burkina Faso); Fondation Performances Sociétales, Social Justice, and Mission des Jeunes pour l’Education, la Santé, la Solidarité et l’Inclusion (Ivory Coast); Malawi Network of AIDS Service Organizations (Malawi); Tanzania Communication and Development Center (Tanzania); Samasha Medical Foundation (Uganda); and Centre for Reproductive Health and Education (Zambia).

Building powerful coalitions for people’s participation

In East Africa, we are supporting the White Ribbon Alliance, a network of civil society organizations and activists working together to improve policies and resources for reproductive, maternal and newborn health and rights. Their “What Women Want” campaign is breaking new ground in lifting up women’s demands for better health services that preserve their dignity, privacy and safety.

In Kenya, White Ribbon Alliance will concentrate on ensuring that adolescent girls and people with disabilities are heard, and their needs taken into account as the government continues to roll-out its UHC program known as Afya Care.

In Uganda, White Ribbon Alliance will focus on ensuring that refugees are well-informed and part of oversight mechanisms for the roll-out of the government of Uganda’s Health Sector Integrated Refugee Response Plan in districts where refugees comprise a large portion of the population (up to 50% in some locations).

White Ribbon Alliance has pioneered the use of citizen charters, town hall meetings, budget monitoring and strategic advocacy as a means for people’s informed and effective participation in oversight of health services. A recent study by Rachel Sullivan Robinson (from the Accountability Research Center at the School of International Service at American University) in Niger State, Nigeria found early evidence that awareness raising campaigns and town hall meetings have created more positive interactions between community members and their local government. These interactions produced specific actions geared toward addressing service provision gaps, for example, more timely release of medical supplies and the employment of more midwives to address staffing shortages.

Tapping into women’s leadership at the community level

In Senegal, CICODEV will support a network of citizen activists, the majority of them women community leaders to carry out grassroots awareness-raising campaigns about the government of Senegal’s universal health coverage policies. These campaigns are designed to ensure that community members understand their rights, know how to enroll in health insurance schemes, and understand the quality and costs of services that they should be receiving at their local health facilities. In addition to these campaigns, CICODEV will conduct periodic surveys of consumers and health facilities to monitor to what extent the services provided match the government’s policy. CICODEV plans to share what they learn from this monitoring with local community leaders and politicians, civic organizations such as women’s and youth groups, district health officials and the Ministry of Health to build momentum for continuous improvement.

Connecting the dots between public policy and people’s experiences

In November we approved a grant for Diakonia, a rights-based intermediary grantmaker, to facilitate citizen participation and oversight of Burkina Faso’s new UHC policy by building upon an existing program known as Prèsimétre.  Prèsimétre supports citizen monitoring of public policies in education, health, water and sanitation, security, governance and other critical social services.

In the first phase of Prèsimétre (funded by the Embassy of Sweden and the European Union) Diakonia organized 26 citizen dialogues with Ministers to discuss issues ranging from water, education, communications and security, offering people from across the country the opportunity to send their questions for live responses. A recent evaluation found that these dialogues are reinforcing a culture of political accountability among Burkina Faso’s national leaders.

For example, in response to people’s complaints during live broadcasts, the Ministry of Infrastructure repaired a bridge to ensure critical road access during the rainy season, and the Ministry of Energy repaired solar power at a medical center in Zorgho.

Diakonia’s local civil society partners have also organized town hall meetings and radio call-in debates for people in 20 districts (rural and urban) across all regions of Burkina Faso to express their priorities and concerns to mayors and other local politicians as they carry out development plans. Mayors have heard and responded to people’s feedback, with actions such as the restoration of water services and construction of new classrooms in schools.  Four communes have now incorporated these citizen forums in their annual investment plans in a move to systematize and sustain them.

With this new grant, Diakonia will provide new funding and technical support to civil society organizations in Burkina Faso to organize awareness raising campaigns and create a variety of virtual and in-person spaces for people to interface with local and national government officials who are responsible for the roll-out of UHC beginning in 2020.

Finally and importantly, all of these organizations are committed to ensuring that women, youth, people with disabilities and other people who often do not have a seat at the table have access to information in their own language and are able to participate in public debates in spaces that are accessible, inviting and safe for them, whether that be a local mayor’s office, a women’s center, a radio call-in program or technology-based platforms such as SMS.

What’s next?

Here are my own working hypotheses for this work:

  • social accountability can narrow information asymmetries between national and local government, health service providers and their clients about what UHC will and will not do for them, and each other’s responsibilities
  • social accountability for UHC can help identify and narrow gaps in the availability of essential resources (money, health supplies, staff), service quality and coverage at the facility level
  • awareness raising and advocacy campaigns can contribute to sustaining the political will for UHC between election cycles, which is when political promises get delivered upon (or not)

I am looking forward to seeing how these efforts evolve, including how the organizations that we are funding adapt in response to changes in political will (positive or negative) and the evolving landscape for UHC.  The grants that we’ve provided to all of these organizations is purposely flexible to allow this sort of adaptation.

I also fully expect that the debate surrounding what and how to measure the results of social accountability will continue (as do others that I have spoken to recently). In that light, I enjoyed reading this recent blog from Sue Cant and Eric Sarriot which puts some of those questions into perspective. Over the next couple of years, we hope to continue to find new ways to contribute to the Transparency, Participation and Accountability field’s knowledge of the potential and limitations of social accountability.

If you’re interested in learning along with us, you can follow me and some of the organizations mentioned in this blog on Twitter.


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