Governance for global health - a view from below

1. Development Studies Association Scotland, Strathclyde University, Glasgow 30 May 2014 Governance for global health -a view from below Dr. Anuj Kapilashrami Lecturer, International Health & Development, Queen Margaret University Hon. Fellow, UoEdinburgh akapilashrami@qmu.ac.uk Work in progress. Not to be cited without author's permission.

2. Governance • Rapidly expanding field of scholarship • Huge variation in its definition and application: as an objective, a process, an ideal (Lee & Kamradt-Scott 2014) “efforts societies make to organize and exercise political power in response to challenges and opportunities they face” (Fidler 2007) • Key determinant of economic growth, social advancement and development Work in progress. Not to be cited without author's permission.

3. Work in progress. Not to be cited without author's permission.

4. Characteristics of GHG • Governance architecture – evolving (re)configuring political space for global health; actors (e.g. World Bank) re-defining their roles (Buse & Walt 2000a; Cohen 2006) • ‘Innovations’ and “trans border agreements or initiatives” between “state and non-state actors” (Harman 2012) • Normative ideas and frameworks – towards ‘good’ governance Work in progress. Not to be cited without author's permission.

5. Paradigm shifts in the complex, open, adaptive system Work in progress. Not to be cited without author's permission.

6. Framework convention on global health • A global health treaty, which establishes robust global governance for health structured around human rights, equity & justice, with legally binding standards, to catalyse accountability mechanisms and guarantee democratic decision making and inclusive participation • A watershed moment? (Gostin 2009/ JALI) Work in progress. Not to be cited without author's permission.

7. The story of Global Fund (CCMs) - key role in steering the focus and direction of programmes; privileging international and national elite networks (Kapilashrami and McPake 2013; Kapilashrami and O’Brien 2012; McCoy 2009 – India, China, Peru and others) Global prescriptive ‘view from above’ ignores local understandings and ways of ‘doing’; and discounts patterns of power, brokerage and patronage that undermine organic processes of reform. Work in progress. Not to be cited without author's permission.

8. Reforms for bottom up governance “Accountability is only possible when those affected have ways to ensure that their needs and concerns are dealt with fairly.” - Rifkin (2003, p 176.) Work in progress. Not to be cited without author's permission.

9. Context- Alma Ata & the People’s Health Movement International Conference on Primary Health Care [WHO & UNICEF; 134 health ministries] Declaration of Alma Ata (1978) “Health for all by 2000” “Existing gross inequality in the health status of the people between countries as well as within countries is politically, socially and economically unacceptable and is therefore of common concern to all countries.” People’s Health Charter (2000) - “Health for all NOW!” Work in progress. Not to be cited without author's permission.

10. “One of the principal reasons why the promise of Alma Ata and the PHC approach did not wither away entirely, is to be found in countless civil society initiatives across the globe” - CSDH CS report 2007 “a significant expression of alternatives ‘from below’ to the present globalization, privatization and commercialization of health coming ‘from above” - Harris & Seid 2004 Work in progress. Not to be cited without author's permission.

11. INNOVATIVE INSTRUMENTS- Right to health campaignPeople’s health tribunals in India(Jan Sunwais – Jan Samvad) Work in progress. Not to be cited without author's permission.

12. Mechanism : People’s Rural Health Watch • Initiated by JSA after the public hearings - To assess the implementation, and impact, of National Rural Health Mission (NRHM) on the health services and support strengthening of the rural public health system • Lessons and directions towards a system of community/ people’s monitoring of health services. Process undertaken as a 2-year initiative over 2006-08; Six questionnaires to guide observations and elicit qualitative information on relevant areas of health services & interviews with facility providers and villagers (> 1000) • Analysis of health budget and financing under NRHM. Work in progress. Not to be cited without author's permission.

13. Community Monitoring Process Work in progress. Not to be cited without author's permission.

14. Tools of Monitoring • Village level [Outcomes – Vill health report cards and Health facility score card] • Village Health Register – records of ANM- public dialogue • Village Health Calendar – Infant and maternal death audit • PHC level & Block level • Charter of Citizens Rights – IPHS, PHC & Block Health Plan • District level • Report from the Block health committees; the District mission committee • Public Dialogue • State level • Reports from the district health committees • Periodic assessment reports by taskforces/ state level committees Work in progress. Not to be cited without author's permission.

15. Conclusion • Most top down/ universal prescriptions on governance tend to offer a linear conceptualization of social accountability and participation that often overlooks the hierarchical and complex nature of health systems and power dynamics that provider-citizen relationships and transactions are embedded in. [utility of social constructivist approaches and critical ethnography] • The desired democratic governance can be achieved by strengthening bottom-up processes in order to make public systems responsive, equitable and effective. Work in progress. Not to be cited without author's permission.