This article poses reflections from two leads of Twaweza, an east African non government organisation, on their approaches and work, particularly in response to a series of blogs on this by D Green (Oxfam GB advisor. They reflect on learning on citizen action; and on the need to better articulate what is meant by citizen action, including private v public and individual v collective. "In essence, this is a move away from an unexplained “magic sauce” model where we feed some inputs (i.e. information) into a complex system, hope twaweza-logothat the (self-selecting, undifferentiated) citizens will stir it themselves, and voila – a big outcome (such as increased citizen monitoring of services, and improved service delivery) will somehow pop out on the other end".
Governance and participation in health
This blog discusses issues and seven lessions raised by evaluations of the theory of change and first four years of work by an East African NGO, Twaweza. The author comments that research by groups like the Africa Power and Politics Programme and Matt Andrews argues that both demand side (build the citizens) and supply side (build the state) have failed in generating change. What works, they think, is collective problem solving, bringing together citizens, states and anyone else with skin in the game, to build trust and find solutions. People on the ground, like Goreti Nakabugo, Twaweza’s Uganda coordinator, get this: ‘we know we need buy-in from the government, officials, local politicians. We are brokering relationships with them on a daily basis’. Not only that, but in practice, even differentiating between citizen and state can be problematic – neither category is a monolith, and in some cases, the most active citizens are themselves state employees, members of public trade unions etc.
Research has shown that mHealth initiatives, or health programs enhanced by mobile phone technologies, can foster womens empowerment. Yet, there is growing concern that mobile-based programs geared towards women may exacerbate gender inequalities. A systematic literature review was conducted to examine the empirical evidence of changes in men and women?s interactions as a result of mHealth interventions. Out of the 173 articles retrieved for review, seven articles met the inclusion criteria and were retained in the final analysis. Most mHealth interventions were SMS-based and conducted in sub-Saharan Africa on topics relating to HIV/AIDS, sexual and reproductive health, health-based microenterprise, and non-communicable diseases. Several methodological limitations were identified among eligible quantitative and qualitative studies. The current literature suggests that mobile phone programs can influence gender relations in meaningfully positive ways by providing new modes for couples health communication and cooperation and by enabling greater male participation in health areas typically targeted towards women. MHealth initiatives also increased womens decision-making, social status, and access to health resources. However, programmatic experiences by design may inadvertently reinforce the digital divide, and perpetuate existing gender-based power imbalances. Domestic disputes and lack of spousal approval additionally hampered women?s participation. Efforts to scale-up health interventions enhanced by mobile technologies should consider the implementation and evaluation imperative of ensuring that mHealth programs transform rather than reinforce gender inequalities. The evidence base on the effect of mHealth interventions on gender relations is weak, and rigorous research is urgently needed.
Using a descriptive literature review, this paper examines the factors that influence the functioning of accountability mechanisms and relationships within the district health system, and draws out the implications for responsiveness to patients and communities. We also seek to understand the practices that might strengthen accountability in ways that improve responsiveness – of the health system to citizens’ needs and rights, and of providers to patients. The review highlights the ways in which bureaucratic accountability mechanisms often constrain the functioning of external accountability mechanisms. For example, meeting the expectations of relatively powerful managers further up the system may crowd out efforts to respond to citizens and patients. Organisational cultures characterized by supervision and management systems focused on compliance to centrally defined outputs and targets can constrain front line managers and providers from responding to patient and population priorities.
In this review, the authors highlight the silos that currently characterise transparency and accountability initiatives (TAIs). The authors argue that a decade on from their inception, and notwithstanding a growth in litigation-based social accountability that invokes popular mobilisation and democratic rights, there is much to suggest that TAIs in aid and development are increasingly being used within an efficiency paradigm, with scant attention to underlying issues of power and politics. Many TAIs focus on the delivery of development outcomes, neglecting or articulating only superficially the potential for deepening democracy or empowering citizens, overemphasising tools to the detriment of analysis of context, of forms of mobilisation and action, and of the dynamics behind potential impact. Many TAIs focus on achieving‘downstream’ accountability –the efficient delivery of policies and priorities – bypassing the question of how incorporating citizen voice and participation at earlier stages of these processes could have shaped the policies, priorities and budgets ‘upstream’. The authors contrast new public management approaches with rights based approaches. The paper examines ways of assessing effectiveness of TAIs.
Advocacy and lobbying are more taking an ever more central place in health agendas of African countries. It is impossible to have a conversation about public policy these days without someone mentioning 'civil society'. The author argues that clarity and rigor are conspicuously absent within civil society. A States' first duty towards citizens is to respect the right to health by refraining from adopting laws or measures that directly impinge on people's health. The paper presents evidence from the literature of civil society organization (CSO) intervention in support of primary health care, equity in health and state health services covering 38 online documents and from interviews with key informants from government and civil society. They suggest from the findings that countries ensure that public health principles and priorities are clear and legally binding; that countries have a clear coordinating mechanism on issues of trade and health that involve government, particularly health ministries and civil society and that civil society disseminate health and trade information in accessible ways.
In the capability approach to poverty, wellbeing is threatened by both deficits of wealth and deficits of agency. Sen describes that “unfreedom,” or low levels of agency, will suppress the wellbeing effects of higher levels of wealth. In this paper the authors introduce another condition, “frustrated freedom,” in which higher levels of agency belief can heighten the poverty effects of low levels of wealth. Presenting data from a study of female heads of household in rural Mozambique, they find that agency belief moderates the relationship between wealth and wellbeing, uncovering evidence of frustrated freedom.
Although gender-based violence (GBV) exists worldwide, it is especially pervasive and challenging in conflict-affected settings. The breakdown of the family unit, high population density, and lack of community safeguards pose obstacles to implementation of GBV prevention programs. Unfortunately, little evidence exists regarding effective GBV prevention interventions in these settings. Through Our Eyes (TOE), a multi-year participatory video project, addressed GBV by stimulating community dialogue and action in humanitarian settings in South Sudan, Uganda, Thailand, Liberia and Rwanda. The authors used evidence from transcripts from focus group discussions and key informant interviews with individuals who created the videos to those who attended video screenings. Data was analysed using a Grounded Theory approach. The assessment found that TOE contributed to a growing awareness of women's rights and gender equity. Furthermore, both men and women reported attitudinal and behavioural changes related to topics such as intimate partner violence. The fostered community dialogue helped de-stigmatize GBV and encourage survivors to access services. Participatory video is argued to have the ability to tailor messages to specific community needs, engage men as key players, foster community dialogue, and initiate social change related to GBV in a variety of conflict-affected settings. The authors argue that public health professionals should employ participatory video as an innovative technique to address GBV and promote positive gender norms within conflict-affected and other humanitarian settings.
This paper outlines stakeholder views on environmental barriers that prevent people who live with psychosocial disability from participating in mental health policy development in South Africa. The authors conducted 56 semi-structured interviews with national, provincial and local South African mental health stakeholders between August 2006 and August 2009. Respondents included public sector policy makers, professional regulatory council representatives, and representatives from non-profit organisations (NPOs), disabled people’s organisations (DPOs), mental health interest groups, religious organisations, professional associations, universities and research institutions. Respondents identified three main environmental barriers to participation in policy development: stigmatisation and low priority of mental health, poverty, and ineffective recovery and community supports. The authors conclude that a number of attitudes, practices and structures undermine the equal participation of South Africans with psychosocial disability in society. They call for a human rights paradigm and multi-system approach to enable full social engagement by people with psychosocial disability, including their involvement in policy development.
The global AIDS response has shown that at the core of health lie considerations of social justice, human rights, and accountability. As momentum builds for a Framework Convention on Global Health (FCGH), the authors of this paper argue that there is an opportunity to take stock of lessons learned from the response to HIV and AIDS and ensure that they are replicated and institutionalised in an eventual Convention. They further argue that the most critical aspect to the success of the HIV response has been the leadership and activism of civil society. Success requires active monitoring of progress and shortcomings, combined with political and social mobilisation to expand investment and access to the services and underlying conditions that protect and advance health. While the FCGH must make civil society support and engagement an indispensable principle, the AIDS movement can contribute substantive content and mobilisation for its adoption. A broad international legal framework for health can help address some of the key legal, policy, regulatory, and programmatic challenges that continue to hinder effective responses to HIV.