Governance and participation in health

Community-led total sanitation (CLTS) is a participatory process focused on promoting change in sanitation behaviour through social action - stimulated by facilitators from within or outside the community. Aimed at empowering local communities this handbook is a source of ideas and experiences to be used for CLTS orientation workshops, advocacy to stakeholders as well as for implementing CLTS activities. It is intended as a tool for field staff, facilitators and trainers to plan, implement and follow up on CLTS activities. A sequence of possible steps and tools, including do’s and don’ts, are provided to help trigger CLTS in a community. They include pre-triggering, selecting a community, introduction and building rapport, triggering participatory sanitation, profile analysis, ignition moment, post-triggering action, planning by the community, follow up, scaling up and going beyond CLTS. Users are encouraged to use and modify the processes outlined in this handbook as they see fit for their given context.

In many parts of Asia and sub-Saharan Africa there is a growing gap between official accounts of how health systems operate and realities on the ground. Researchers in this study looked at how to gain access to competent health care in environments where there are growing but unorganised markets in goods and services, blurred boundaries between the public and private health care sectors, and a lack of state regulation. The researchers used the frame of the ‘social contract’ (an implicit agreement among people that results in the organisation of society) and focused on the problem of information asymmetry (inequalities in access to information) and associated power relationships, in particular those between patient and health care provider. Their paper highlights the importance of trust to relationships at all levels of the health system. Findings show that different ways of generating trust in goods and services, and new forms of regulation have emerged. The researchers call for greater understanding of the institutional context in which health systems operate in developing countries. They also stress the need to avoid dictating policy according to the experiences of developed countries. Instead, future debates will need to focus on how governments can create regulatory partnerships and enable improved access to information, building on the new social contracts that are already emerging.

From Poverty to Power, Oxfam International's new book, provides critical insights into the massive human and economic costs of inequality and poverty and proposes realistic solutions. It proposes that the best way to tackle them is through a combination of active citizens and effective nation states. Why active citizenship? Because people living in poverty must have a voice in deciding their own destiny, fighting for rights and justice in their own society, and holding states and the private sector to account. Why effective states? Because history shows that no country has prospered without a state structure than can actively manage the development process.

Participation is important in developing countries as a means of improving the performance and accountability of bureaucracies and improving social justice. There are two basic criteria for participation: it should be broadly representative of the population and should involve meaningful discourse that affects public decision-making. Reviews of participation in Poverty Reduction Strategy Paper (PRSP) processes show that these criteria have not been met in most cases. However citizen involvement in budgeting has been more successful. Citizen participation made local service delivery more efficient and effective in the country cases reviewed. In most of the case studies, NGOs analysed the budget and mobilised citizens. These NGOs seek to represent the poor and disseminate their views to the government. They do not offer direct citizen involvement, but without their involvement participation would be reduced. Budget participation can influence governments even where they have not embraced direct involvement of citizens in decision-making. This depends on NGOs communicating analyses of spending choices, public service effectiveness, and budget execution to the public, media, and elected officials. A key policy implication for donors is therefore targeted support to civil society. However, donors and NGOs often overlook the importance of government administrations in implementing participation.