In this paper, the author analyses governance gaps in healthcare systems in sub-Saharan Africa and how they could be overcome, with a particular focus on the areas of budget and resource management, individual provider performance, health facility performance and corruption. She attributes poor governance to the effects of a range of factors. Budget leaks, which refer to the discrepancy between the authorised health budget and the amount of funds received by intended recipients such as frontline providers, undermine service provision, as do high levels of health worker absenteeism. Job purchasing, which refers to payments made by job-seekers in exchange for employment in the public sector, a practice that often bypasses appointing on merit, is another common practice, which results in poor quality staff. On the financial side, chronic underfunding of health facilities and corruption at management levels are the other dimensions of poor governance in the health sector. The author urges governments and external funders to not only focus on the input and outputs, but also to ensure that these resources are used effectively to ensure maximum impact on health outcomes.
Governance and participation in health
What did South African AIDS activists contribute, politically, to early international advocacy for free HIV medicines for the world's poor? Mandisa Mbali demonstrates that South Africa's Treatment Action Campaign (TAC) gave moral legitimacy to the international movement, which enabled it to effectively push for new models of global health diplomacy and governance. The TAC rapidly acquired moral credibility, she argues, because of its leaders' anti-apartheid political backgrounds, its successful human rights-based litigation and its effective popularisation of AIDS-related science. The country's arresting democratic transition in 1994 enabled South African activists to form transnational alliances. Its new Constitution provided novel opportunities for legal activism, such as the TAC's advocacy against multinational pharmaceutical companies for blocking access to affordable generics and the South African government when it failed to provided antiretrovirals. Mbali's history of the TAC sheds light on its evolution into an influential force for global health justice.
The Millennium Declaration of 2000 contains a comprehensive vision of development underpinned by human rights, and is the source document of the Millennium Development Goals (MDGs). However, in 2001, when the MDGs were formulated, influential voices were able to convince the international community that democratic freedoms could be relegated in favour of progress on economic indicators. But the neglect of these freedoms has come at a cost, the author argues, as evidenced by the Arab Spring, which showed that development must be about both freedom from fear and freedom from want. People need good standards of living where their basic needs are met but they also need civil and political freedoms to have a say in the decisions that affect their lives and to ensure that the benefits of development are evenly spread. The author calls on global and national decision-makers to reread the promises made by world leaders in the Millennium Declaration on freedom, equality, solidarity, tolerance, respect for nature and shared responsibility. He argues that it is time to put people at the centre of development and ditch the business as usual approach if we are to address impending and interlinked economic, social, political, environmental and humanitarian crises.
As debate intensifies on the future of the post-2015 sustainable development agenda, participating organisations in Beyond 2015 came together to develop this joint position paper to advance the concept of just governance. Just governance in the post-2015 era would first require a reconception of sustainable development goals not as needs and services but as rights accessible to all. Just governance likewise implies that the framework that replaces the Millennium Development Goals must include an explicit focus on equality and equity across all development goals, geared towards ensuring that those who are most marginalised participate in the benefits of development. Finally, just governance implies accountable governance for all relevant actors at all levels, based on a clear mandate regarding who is responsible for what post-2015 commitments.
To further accelerate progress in the run-up to the Millennium Development Goal (MDG) deadline in 2015, and to ensure sustained progress beyond this date, civil society argues in this report that openness – especially transparency, accountability and public participation – must be at the heart of the post-2015 development framework. They call on the High-level Panel of Eminent Persons (HLP) to pioneer a high-impact agenda through a series of concrete recommendations to the UN Secretary-General. The recommendations should be guided by the promotion of: (1) an open process for soliciting and responding to the priorities and concerns of the world’s poorest people; (2) open, comprehensive and timely reporting on investments and outcomes in pursuit of the agreed development goals and targets, along with enhanced opportunities for citizen participation; and (3) the establishment of open data platforms to ensure that progress can be transparently tracked, lessons can be learned on a real-time basis and all stakeholders can be held accountable.
At the final meeting of the United Nations Thematic Consultation on Governance and the Post-2015 Framework, held in Johannesburg at the end of February 2013, participants argued that human rights and accountability must be placed at the heart of governance at the national and global levels. A high point of the meeting was the address by High Level Panel member Graça Machel, who spoke of the panel´s commitment to ensuring that issues of governance, human rights and inequality were central to the new post-2015 framework. There was wide consensus at the meeting that weak and unaccountable governance, including at the global level, is one of the key issues that must be addressed in a future framework, and that democratic governance must be predicated on respect for the full range of human rights. Ultimately, it will be up to the international community to decide the parameters of the successor framework when it gathers for the Millennium Development Goal Review Summit in New York in September 2013. In this article, the author calls on global civil society to promote rights-based governance in the run up to this important event, which is likely to prove pivotal for the future of international development.
At the end of the Eleventh CIVICUS World Assembly, held in September 2012, the various recommendations made by delegates were analysed and distilled into 15 key commitments for civil society to implement as it seeks to work more effectively to promote equity and to challenge and change the rules of engagement between citizens, the state and other holders of power. Some of these commitments call for greater networking and smarter partnerships between formal civil society organisations and new social movements and social media technologies. The significance of encouraging local and voluntary participation, maintaining community connections and addressing marginalisation was highlighted. Other commitments argued for work within an equity and human rights based framework that includes sustainability and demands accountability to citizens, not external funders. Civil society also needs to be less dependent on governments and seek alternative financing models, like social and crowd-sourced funding. The commitments further call for civil society organisations (CSOs) to be innovative, strategic and have an assets-based approach, develop a better understanding of private sector involvement as well as develop CSO capacities for negotiation and analysis of power.
In this interview, CIVICUS Secretary General, Dhananjayan Sriskandarajah argues that civil society has the potential to find solutions to our greatest global challenges based on equity, participation and sustainability. Civil society participation is now of greater significance as the development paradigm is changing faster than the key players realise. Official aid flows are becoming less important, new actors such as China and India are blurring the boundaries between development and business, and Big Business has moved in to take advantage of potential profits to be made from the 'aid industry'. He identifies two key mechanisms for responding to these changes and to ensuring progress on the development agenda: global commitments that involve all key actors and set real targets, and local action that finds new ways of involving citizens in shaping the development process. He also criticises current multilateral processes where the negotiating positions taken by diplomats do not reflect the wishes of their citizens. At these meetings, principles of human rights, democracy and environmental sustainability disappear from the agenda and narrow interests emerge that do not arise out of any popular mandate. He calls for new ways of holding governments to account for the positions they take on the international stage.
Despite being some of the most taxed citizens of the world, Kenyans have so far had little say in how their economy is managed. The Constitution of Kenya (2010) has, however, given much impetus to ordinary citizens participate in the management and decision-making process in governance socially, economically and politically. Participatory budgeting is a mechanism that civil society can use to decide how to allocate part of a municipal or public budget. In collaboration with Fahamu, in September 2012, the Kwale community engaged in a needs assessment process after which the priority areas were identified before electing budget delegates at the ward level. Kwale County currently has 20 wards following the recent boundary demarcations by the Andrew Ligale-led Interim Independent Boundaries Commission. The 20 wards are in Matuga, Msambweni, Kinango and the newly created Lunga-Lunga constituencies. The ward delegates are charged with developing specific spending proposals which will later be presented to the community for validation. If the community approves of the proposals, the same are to be forwarded to the county government for consideration of implementation. If implemented, participatory budgeting is expected to raise the social and economic well-being of the two counties. Areas that are expected to benefit significantly include education, health, agriculture, roads and energy sectors.
The aim of the “Open for Development” campaign – and the global petition – is to persuade the High-Level Panel on the post-2015 Millennium Development Goals to ensure that openness forms the basis of the next global development framework. In this petition, ONE is calling for three things: 1. Openness in the design of the post-2015 framework to ensure that the post-2015 goals reflect people’s needs and priorities. 2. Openness in the monitoring of investments and outcomes so both funding and recipient governments collect information about what they spend and what they achieve in pursuit of the goals. 3. Openness in terms of making that information widely available and accessible so citizens, parliaments and the media can use it hold governments to account. The global petition urges world leaders to make sure the plan to end extreme poverty is specific, measurable and accountable.