"Bridging the divide” Using Social Accountability as entry point for improving Health for ALL

1. "Bridging the divide”Using Social Accountability as entry point for improving Health for ALL Kirsten Havemann, MD, MPH, PhD DANIDA

2. Outline What do we know? What would we like to know? 3. What would we like to do?

3. In many countries average health is improving but inequity is increasing Under 5 mortality (per 1000 live births) by wealth group

4. What good does it do to treat people’s illnesses ….. ……and send them back to the conditions that made them sick

5. Technical Approach Governance Approach Technical Quality Social Accountability matters Building an effective Health System for equitable health outcomes Timing and Continuity Relevance of Services Organisational Quality Availability of Material Resources Availability of Human Resources Physical Accessibility (availability and accessibility)

6. The Routes of AccountabilityCentralized – Decentralized Systems

7. What is Social Accountability? Social accountability refers to the broad range of actions and mechanisms beyond voting that citizens can use to hold the state to account, as well as actions on the part of government, civil society, media and other societal actors that promote or facilitate these efforts.

8. Examples of Social Accountability … • Transparency:Participatory planning, budgeting, monitoring and evaluation- demystification of public info; • Accountability:Health Budget analysis and tracking; informing/initiating parliament investigations; • Rule of Law: legal rights campaigns/support; filing complaints; class action suits; • Voice: Community Score Cards ; media campaigns; Patients Charter , Public Notice Boards

9. Some preliminary Results In Nepal neonatal mortality decreased by 30% (Manandhar et al., 2004) through participation of women in health service provision; In Kenya malnutrition was significantly reduced by 6-8% per year through strengthening voice and power and building capacity of both users of services (Havemann 2004); In Burkina Faso community participation in primary health care clinics raised immunization coverage, the availability of essential drugs, and the percentage of women attending ante-natal care (Eichler, 2001); In Peru, governance in primary health care was associated with decrease in staff absenteeism, waiting time and improved quality of services (WB, 1999; Ewig, 2003)

10. 2. What we would like to know?

11. How can one enhance Accountability? There has been varying success with these. What has been learnt is that success often depends on equal opportunity to participate by people 1. Rules and Regulations – administrative procedures, audits,… 2. Bring in Market Principles– privatization or contracting out to private sector and NGOs 3. Independent Agencies– ombudsman, vigilance commissions,… • 4. “Social Accountability”

12. Building Blocks for Social Accountability

13. 3. What we would like to do?

14. EntryPoints

15. But…there are risks The introduction or strengthening of citizen-state bridging mechanisms (mistrust) The willingness and ability of citizen and civil society actors to actively seek government accountability. The willingness and ability of service providers and policy makers to account to the public. The broader enabling environment

16. Thank you Small victories contribute to success.