Service Accountability and Community Participation in the context of HSRs in Asia: Implications for SRH Services

1. Service Accountability and Community Participation in the context of HSRs in Asia: Implications for SRH Services Ranjani.K.Murthy, with Barbara Klugman Rights and Reforms Team members (coordinated by WHP, South Africa)

2. Questions this paper has raised What is the understanding of community participation and community accountability underpinning World Bank initiated HSRs and outside? Who is the community? Through what mechanisms and to what extent do marginalised people participate in health policy and management within and outside HSRs in Asia? Has their participation enhanced responsiveness of public health system to their needs, and strengthened provision of SRH services? Are there non participatory strategies for strengthening accountability to communities? Are the assumptions that CF, decentralization and regulation further accountability valid? Do the community, political and health system contexts in Asia have a bearing on CP and accountability to communities?

3. 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

4. Community Participation in health/SRH services:Lower to higher order of participation

5. Community Accountability Alternative perspective Expand answerability of government to public Enforce penalties when not accountable Sees vibrant democracy as prerequisite Neo liberal Privatization/competition Community financing, decentralization, community health structures, regulation Views that accountability can be added on through reforms irrespective of contexts

6. Accountability: Lower to higher order of accountability to communities

7. Asia context More literature on CP/AC in practice on: India, Bangladesh, Philippines, Indonesia, Malaysia, China, Pakistan?? Diversity : History and vibrancy of democracy Levels of poverty and gender inequalities Health budgets, expenditure and financing SRH policies and legislation

8. Key findings: CP and AC in HSRs Of 18 World Bank initiated HSRs in Asia, 12 include a component of community participation or accountability Actual reforms have adopted the following strategies uniformly across regions: community health structures (Bangladesh, Cambodia), District health structures (Andhra Pradesh, Orissa, India), - community financing (North West Provinces, Pakistan, Orissa, India) strengthening devolution (Philippines), or de-concentration (India) A few reforms stakeholder participation in policy (Bangladesh, Cambodia) Strengthening professional associations (Indonesia), community volunteers (Cambodia) Client regulation-promoting patient rights charters (Bangladesh) , government regulation-superintendence (Cambodia)

9. CP and AC in HSRs continued More examples of participation at service delivery/programme management level, than policy level, i.e furthering managerial than political accountability Community: means 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 39% of 18 HSRs in Asia have prioritised at-least one SRH service, which sets boundaries of impact of CP and accountability mechanisms

10. CP and Ac in HSRs continued Few studies on SRH impact of CP or AC 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 Low priority SRH services not addressed: reproductive cancers, infertility treatment

11. CP and accountability outside HSRs CP and accountability strategies more diverse: budget allocation and programme implementation monitoring (Health Watch and Karnataka health task force, India) Advocating of accountability legislation: Anti-corruption act, right to information act, (India) Mobile Ombudsman Centres run by government (India) public interest litigation when rights to health services and SRRs are violated (various groups, India), public hearings around health situation, implementation of policies and expenditure (Thailand, India) mortality audits (Indonesia) accreditation of government hospitals (Malaysia) More context specific- diverse across countries If happening in invited spaces level of participation and outcomes only slightly better than in HSRs,

12. Where in demanded spaces Community financing as a strategy for strengthening community accountability has never been demanded Higher level of community participation, where 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

13. Factors that influence the impact of CP and AC on SRH services The legal and policy environment pertaining to SRH The broader economic, political and cultural milieu The health budget and institutional context The strategizing skills of CSOs The SRH sensitivity and competence of different stakeholders The project context within which CP and AC occurs Need to choose according to context

14. Key Discussion points Can HSRs promote participation and accountability in non democratic spaces, inadequate budgets, weak policy/legislation on SRH, lack of independent judiciary? Without resources and investment in capacity building by the state can CP or accountability can happen?. Being aware of, and countering, the negative consequences

15. Advocacy agendas Influence health/SRH legislation, 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 CF, community health structures, or all models of decentralization promotes accountability Engage with HSRs/researchers working on HSRs shape reforms themselves (priority setting, financing, model of decentralization), push reforms to further a policy on CP and AC at national, provincial, district and lower levels Promote innovative AC strategies which are common outside reforms Promote participation contracts between WB, government and CSOs Budget for capacity building of civil society actors

16. Research * Country level and context specific analysis of CP and accountability within and outside reforms, and their impact, and how the other elements of HSRs in that specific country interact/influence CP and accountability outcomes (with respect to SRH services) * To bridge country specific gaps in literature. Other than India, Bangladesh, Philippines, South Africa, China there is little information on other countries on this issue * 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

17. Capacity building Sensitise national governments, aid agencies, specialists working on HSRs on community participation and 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