‘Mutual-learning at accountability’s cutting edge – a practitioners’ consultation on improving Health and Nutrition services in South Asia’*
SUMMARY OF DAY 1 (March 16, 2016) of DISCUSSION on Social Accountability for Health and Nutrition in South Asia: Relation with service providers
Topics covered in the online discussion were:
1. Community participation and engagement
To the question ‘how do organizations on the ground ensure community members are engaged and lead social accountability efforts?,’ participants illustrated how any social accountability process with raising awareness and informing community members over rights and entitlements. This step entails creating a ‘culture of questioning’ which is crucial to mobilize communities around issues of healthcare and basic services. In this sense, the rights-based framework is essential to build the culture of questioning, and more importantly to provide a framework for social action. Furthermore, this process is not only limited to raising awareness over specific rights and entitlements, but also building awareness on wider social and policy structures, the role of democracy, and the way state functions. Some organizations include frontline service providers in this process, to fill the knowledge gap among health providers and ensure shared goals and vision.
Community participation can rely on a number of different tools. Participants mentioned, among others, community scorecards, cases documentation, social audits etc. These are chosen based on the type of data that needs to be collected, and at times the choice is also influenced by funders’ requirements. As rightly pointed out, the effectiveness of social accountability tools does not depend on the type of tool chosen, but on the strategy built around it: ‘tools are just medium to create environment in the community so that people can sit together and start talking about the issues.’ Ground experience has shown that while negotiating with service providers, the leverage points that a specific tool can open up for communities is context-specific.Motivation, incentives and social recognitions are concepts crucial to ensuring participation of community members. Equally important is setting clear, reachable goals. However, questions remain with regards to sustainability and ‘institutionalization’ of accountability processes.
During this process, special attention needs to be placed towards inclusion of particularly marginalized sections of the community. For instance, raising women’s voices, especially with regards to sexual and reproductive health and rights, is particularly challenging in contexts where gender, caste and religion hinder people’s participation (e.g. ability to attend community meetings) and ability to address specific issues (e.g. family planning). Here, social accountability processes can be useful to resist oppression and ensure representation of vulnerable groups. Some organizations address intra-community divisions by ensuring each group within the community can participate to community monitoring, and present their views (and needs) about the state of healthcare delivery. In the case of some women groups, solidarity and intercommunity support is essential to collectivize actions, and give the group a stronger voice.
In addition, community participation processes can provide a valuable opportunity to engage men in conversations about healthcare, particularly family planning, and in turn counter those gender dynamics that affect women negatively.
2. Negotiating with the State
Data collected through community monitoring is then presented to and discussed with government health providers at different levels. In some cases, local service providers also participate to the monitoring process and provide their own data. Most of the participants indicated that the negotiation at local level happens through existing committees or ad-hoc platforms set up by local groups. Some of these committees are established under government schemes (like the Village Health and Nutrition Committees in India), but become properly functioning only through Social accountability interventions. In other instances, new platforms or opportunities for dialogues need to be created ad-hoc.
Some participants mix collaborative and confrontational approaches when dealing with health providers. More confrontational approaches, including dharnas and litigation, can be recurred to in particularly serious cases of health rights violations or to advance strategic claims.
It has been pointed out that negotiation is usually easier at community level, where frontline workers and patients live side by side and find ways to collaborate, but it becomes more difficult to translate local demands into wider changes. Here, an essential step is the aggregation and analysis of information collected at community level (some participants also indicated ICT-based solutions for systematic and anonymous gathering of data). This data is brought to the attention of District or Province/State level discussion forums (mirroring the community-level committees) between civil society and government representatives. Participants’ work and experience pointed out that when locally-collected data is used to push for better service delivery at ‘higher’ levels (such as District or State), community members are seen as legitimate sources of information, and their voice becomes more legitimate.
Lastly, good examples of ‘vertical integration’ and continuous exchanges between various levels (community and District/State) come from the work some of the participants have been doing around budget. Budgetary considerations are essential when advocating for improvements of health service delivery. Some of the participants’ work focuses on unpacking public health budget, and facilitate communities’ inputs on budget allocations. Here, the community participation process leads to the formulation of ‘key asks’ for the government. This approach has led to the state initiating consultations with communities during the formulation of budgets.
3. Accountability of the private sector
The third and final, topic discussed concerns the role of social accountability processes in demanding (and obtaining) accountability from the private sector. When speaking about ensuring accountability in the delivery of healthcare, the private sector is a crucial piece. Regulation of the private health sector is indeed very critical and urgent task. Lack of regulation means lack of an effective framework for claiming accountability in service delivery. Moreover, the relations patients-private providers is of an economic nature that doesn’t follow the paradigm of rights and duties.
With the exception of one example from Pakistan, in most of the contexts where participants work, there is a lack of effective channels for dialogue and grievance redressal. The leverage points community members have are virtually non-existent. This issue can only be addressed by stressing the role of the Government as main responsible for healthcare provision and regulation. This agenda must essentially be pushed at policy level however the decision-making spaces and processes are neither transparent nor accountable to the principle of ensuring access to quality healthcare.
*The summation provides sneak peek into a collaborative initiative of COPASAH with Institute of Development Studies (IDS) of online discussion on Social Accountability for Health and Nutrition in South Asia, March 16- 17, 2016.