Participating voices: Constructing Programmatic Change for Inclusive Policies

1. Participating voices: Constructing Programmatic Change for Inclusive Policies Ariel Frisancho Arroyo “Improving the Health of the Poor: a Human Rights Approach” Program Manager (CARE Peru) afrisancho@care.org.pe The Demand for Good Governance Summit June 2, 2008 World Bank / Washington, D.C.

2. General Information • Program purpose: to strengthen Peruvian state / society relations in the health sector, promoting poor people’s health rights • Expected outputs:a) Civil society organisations develop and strengthen strategies for making health sector policies and institutions respond to, protect and promote health rights, especially of the poor and marginalized people; b) Civil society and health providers have developed participatory and inclusive mechanisms for planning, provision and evaluation of health services • 2004: DFID / 2005-2008: DFID, through PPA w/CARE UK

3. CARE’s Health Rights Program & World Bank’s Accountability Triangle NATIONAL GOVERNMENT Responsiblefor Policy Making Prioritization of Social Expenditure, Management Agreements, Standards for Health Services’ Payment Demands to congressmen, Claims through coalitions as ForoSalud, Regional Health Councils Politicians, congressmen MoHealth, MoEconomics, MoLabour Health Services Users’ Rights Law Ministry of Health Decentralisation Devolution, delegation ForoSalud (Main Civil Society Health Network) Health Policies Capacity Building on Health Rights & Participation SUB-NATIONAL GOVERNMENTS Social Surveillance >Voice >Participation National Regional Provincial Public Insurance Ombuds-person Office POLITICAL VOICE Contract / Agreement Participatory Monitoring Alliances Civil Society LOCAL GOVERNMENT COALITIONS & CITIZENS PROVIDERS USERS’ EMPOWERMENT Physicians & other Health providers Hospitals, Health facilities and private clinics Control of CLAS Assembly Participation in Health Local Plans Participatory Budget, Choice on Provider Non-poor Health Services Users Poor Health Services users Participatory planning & monitoring of CLAS Citizen Surveillance Mechanisms & Women Empowerment Improving:

4. Is it possible for citizens and civil society organizations to propel participatory strategies for making public policies and officers/ authorities to contribute with the realization of health rights?

5. Strengthening CS Influence on Health Policies • HR Program linked up with ForoSalud, the most extended nation-wide civil society network in health, to build capacity to participate in decisions about health • Training on health rights and developing capacities for collective action and advocacy brought people’s bottom-up constructed policy proposals to regional / national policy dialogues • ForoSalud members elected as people representatives in National Health Council / 10 Regional Health Councils; some ForoSalud policy proposals institutionalized (i.e. Mental Health, Health Promotion, etc) • ForoSalud is now positioned as a key actor within Peruvian health sector, demanding consultative processes for social and health policy design, M & Evaluation • ForoSalud has advanced in its own democratization and decentralization process, and is currently building increasing representation of the most poor and excluded in its own structures. • The recently appointed Peruvian Minister of Health (December 2007) has publicly recognized ForoSalud as a both political and technical key actor within Peruvian health sector.

6. ForoSalud Influence on Health Policies: Outputs • 2002 –3: w/ women organizations’ defense on SRH priority • Along 2004: Bottom-up processes to construct health policy proposals analyzing: 1) Traditional health problems; 2) key social determinants of health and 3) challenges on responsiveness of health system to people needs. Approach incorporated nation-wide in 2006 by MoH. • 2005 -6: Nation-wide campaign raising awareness on challenges USA - Peru Free Trade Agreement could generate for access to medicines/now taken into account for FTA implementation. • 2007: w/ women leaders’ citizen surveillance scheme in Puno turned inspirational to the Minister of Health: he has propelled MoH surveillance committees for the national hospitals • 2008: ForoSalud representatives in the National Health Council successfully obtained the Minister of Health support and the National Health Council approval of a Law proposal to balance composition of "invited spaces", including the realization of National Health Conventions, with a bottom-up approach for the participatory presentation and discussion of the new government health policy and commitments.

7. ForoSalud + CARE Peru multi-level Accountability Approach International “Shadow report”: civil society follow-up on Paul Hunt (UN Special Rapporteur on Health Rights) Recommendations to Peru National Law proposal on Health Services users Rights & Responsibilities Balancing power-relations within “invited spaces” for policy dialogue & negotiation Regional & Local with ForoSalud, PHR USA & Ombudsperson Regional Office: Citizen surveillance on health services and social programs quality & effectiveness in Piura & Puno regions, linking Quechua and Aymara women community leaders to regional offices of the Ombudsperson to monitor women’s health rights, particularly their right to good quality, appropriate maternal health services

8. Lessons learned • Participation as a means for influencing public health policies and as an end in itself for empowerment & building of citizenship • Social communication: dissemination of health rights • Support the social movement agenda, with no intention on imposing the aid agency agenda(“trust the locals”) • Strengthening ‘Voice’ is not enough to strengthen governance: work with both the demand and supply sides • Multi-level interventions addressing a) capacities of both right-holders and duty bearers, b) strengthening dialogue spaces and c) broader policy environment, through social communication strategies to raise awareness amongst public opinion. On the other hand, Development Aid could be very influential promoting rights & better governance

9. Rights holders Duty-bearers Layer 2: The actual point of interface between the community and the duty-bearers, where idea interchange, negotiation and service delivery occurs. √ √ √ √ √ √ √ √ Layer 1: Capacities both community and the duty-bearers need to enter effectively into a relationship of dialogue, negotiation and decision making Layer 3: Broader policy environment enables or constrains that relationship. Model for Governance & Rights Engagement Layer 4: The international community might become very influential in promoting rights, participation and government fulfillment of its obligations; Or, it might not. Key assumption - strengthening ‘Voice’ is not necessarily enough to strengthen governance. (Based on a graphic of Goulden, J., adapted by Frisancho, A. Please send comments and inquiries to: afrisancho@care.org.pe)

10. Strengthening MoH Ownership of RBA • Window of opportunity: upcoming visit by the UN Special Rapporteur on the Right to Health and newly appointed Minister of Health (2004) allowed CARE to address institutional shortcomings in cooperation with MoH • MoH improved relationships with civil society; placed inclusion and cultural appropriateness as institutional priorities and created technical units to work health rights contents within MoH. • 2004-06: National Mobilization on Health Rights; implemented macro-regional workshops & training on health rights and citizen participation; sanctioned norms to include cultural preferences within health care practices. • Participatory construction of CLAS Law (2005-08)

11. Chief challenges • Social indifference facing the exclusion of the poor • Facing weak legal enforceability mechanisms, need of strengthening responsiveness, engagement and accountability from public health services and MoH • Historical top-down relations and power inequities between health providers and community (“patrimonialismo”) • Promoting social rights involves risks: authorities misunderstanding of CARE role, when contributing to address institutional shortcomings and systemic inequity • Lack of personnel within the regional Ombudsperson offices, i.e., six officers for a whole region • Engaging local experiences with major stake - holders from the start: promoting ownership (early appropriation)

12. Lessons for Development Aid Agencies • “Accountability Triangle”: working with demand (long run, short run) as important as strengthening government development programs • Advocacy processes demands capacity building • Importance of strengthening the interface between community and state: national decentralisation processes should give attention not only to the “quantity of participation” provided by new participatory mechanisms, but to its “quality” (representative-ness, “voice” brought to decision making tables, etc) • Promoting governance and empowerment demands time and a more flexible approach which are more difficult to get incorporated within traditional co-operation deadlines and frameworks