AID EFFECTIVENESS - Action for Global Health
AID EFFECTIVENESS - Action for Global Health
AID EFFECTIVENESS - Action for Global Health
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<strong>AID</strong> <strong>EFFECTIVENESS</strong><br />
progress and the status quo of democratic ownership and<br />
meaningful civil society participation in the health sector
2<br />
ACKNOWLEDGEMENTS<br />
<strong>Action</strong> <strong>for</strong> <strong>Global</strong> <strong>Health</strong> would like to thank<br />
the people who contributed to this report,<br />
including our consultants Madhusudan<br />
Sharma Subedi (Nepal), Elias Salvador<br />
Ainadine (Mozambique) and Roxana María<br />
Rodríguez (El Salvador) and all the civil<br />
society and government representatives active<br />
in the health sector in Nepal, El Salvador and<br />
Mozambique who agreed to be interviewed.<br />
This report was produced by <strong>Action</strong> <strong>for</strong> <strong>Global</strong><br />
<strong>Health</strong> and written by Alice Schmidt,<br />
consultant.<br />
Published in July 2011.<br />
CONTENTS<br />
eXecutive summary: 3<br />
BacKground & introduction: 4<br />
aim & methodology: 5<br />
part 1: cso participation in<br />
improving aid effectiveness: 5<br />
part 2: case study analysis &<br />
comparison Between el<br />
salvador, mozamBique & nepal: 8<br />
el salvador: 8<br />
mozamBique: 10<br />
nepal: 13<br />
other countries: 14<br />
eXamples of Best practice: 16<br />
part 3: cross-country<br />
comparisons & conclusions: 18<br />
recommendations & lessons<br />
learned: 20<br />
references & further reading: 22<br />
Cover Photograph: G.M.B. Akash/Panos/<strong>Action</strong>Aid<br />
Inside Cover Photograph: DSW<br />
Photograph: DSW
aid effectiveness<br />
3<br />
eXecutive summary<br />
Ownership is the first of the five principles set out in<br />
the Paris Declaration on Aid Effectiveness.<br />
Democratic ownership of development processes<br />
includes parliamentarians, civil society and the<br />
private sector. However, in practice, the principle of<br />
ownership is all too often interpreted as<br />
‘government’ ownership only. Based on three<br />
country case studies and the review of wider<br />
literature, this report presents an overview of recent<br />
developments and the status quo of civil society<br />
participation in development processes.<br />
Civil society participation in development policies is<br />
important <strong>for</strong> a number of reasons: <strong>for</strong> example,<br />
civil society can provide a mechanism <strong>for</strong> checks<br />
and balances, enhance government accountability<br />
and transparency by acting as a watchdog,<br />
represent the voices of poor and marginalised<br />
people.<br />
In the Paris Declaration 2005, and three years later<br />
in the Accra Agenda <strong>for</strong> <strong>Action</strong>, governments<br />
committed to “encouraging civil society<br />
participation” in coordinating aid and to “deepen”<br />
their “engagement with CSOs as independent<br />
development actors in their own right whose ef<strong>for</strong>ts<br />
complement those of governments and the private<br />
sector”. In other words, governments and donors<br />
agreed to support broad consultative processes in<br />
the development and implementation of national<br />
strategies and acknowledged that civil society<br />
actors have a legitimate role to play in the design<br />
and implementation of country health plans.<br />
As a result, substantial ef<strong>for</strong>ts have been made in<br />
inviting civil society to consultations. Overall, civil<br />
society participation has improved, and this is a<br />
point on which governments, donors and civil<br />
society tend to agree. However, despite these<br />
quantitative improvements in civil society<br />
representation, as demonstrated in a number of<br />
recent reviews, there is no conclusive evidence on<br />
progress in regard to qualitative aspects of civil<br />
society representation. For the time being there is<br />
only anecdotal evidence that, nevertheless,<br />
provides some room <strong>for</strong> cautious optimism.<br />
However, in most countries, there is ample scope<br />
<strong>for</strong> improved civil society participation and <strong>for</strong> more<br />
development partners to provide support <strong>for</strong> more<br />
meaningful participation.<br />
In El Salvador, there are a number of <strong>for</strong>mal<br />
mechanisms <strong>for</strong> civil society participation. For<br />
example, in 2010 a National <strong>Health</strong> Forum was<br />
established to allow <strong>for</strong> consensus-based decisions<br />
in the development of a national health system built<br />
on the right to health, universal coverage, inclusion,<br />
quality and civic engagement. Strong ef<strong>for</strong>ts are<br />
being made to adequately represent sub-national<br />
concerns, resulting in CSOs at all levels feeling<br />
well represented. Many CSOs have received<br />
advocacy capacity building and it is felt that civil<br />
society views are adequately reflected in most key<br />
health-related policies. Nevertheless, civil society in<br />
El Salvador is struggling with polarisation along<br />
lines of political affiliation, as well as defensive<br />
attitudes and distrust by the Government towards<br />
CSOs.<br />
In Mozambique, the main health coordination<br />
mechanism does not involve civil society.<br />
Nevertheless, the Government launched a<br />
Development Observatory to establish a<br />
permanent mechanism <strong>for</strong> hearing the concerns<br />
and aspirations of civil society organisations as<br />
early as 2003. The Observatory has since<br />
expanded to all provinces, thus allowing <strong>for</strong> subnational<br />
representation. Nevertheless, not all CSOs<br />
feel well represented and there is a view that both<br />
governments and donors tend to invite few, handpicked<br />
organisations to consultations only.<br />
Moreover, even those ‘usual suspects’ do not<br />
always feel that their views are adequately<br />
reflected in outputs and outcomes of consultation<br />
processes. A somewhat antagonistic relationship<br />
between governments and civil society means that<br />
spaces created <strong>for</strong> civil society participation are not<br />
always used to their full extent.<br />
Nepal has a very diverse civil society that appears<br />
particularly difficult to coordinate. Real ef<strong>for</strong>ts at<br />
systematic sub-national or otherwise<br />
representation in national-level consultations does<br />
not seem to exist, neither by civil society itself nor<br />
by the government and development partners.<br />
While Joint Annual Review meetings do bring<br />
together all partners, including civil society, they<br />
provide little practical opportunities <strong>for</strong> civil society<br />
to share and discuss its views. Despite these<br />
constraints, the concerns of marginalised<br />
populations and those living in remote areas do<br />
seem fairly well reflected in national health policies,<br />
and access to primary healthcare has improved in<br />
recent years.<br />
Obstacles to meaningful participation of civil<br />
society that are common in most countries include<br />
a lack of multi-sectoral mechanisms that <strong>for</strong>mally<br />
and systematically involve civil society, particularly<br />
national and local CSOs; poor ef<strong>for</strong>ts at recognising<br />
the diversity of civil society when selecting<br />
participants <strong>for</strong> consultation; a certain degree of<br />
distrust between government and civil society;
4 aid effectiveness<br />
limited civil society capacities to engage in policy<br />
processes; and a skewed balance of power<br />
between governments, donors and civil society.<br />
Nevertheless, there are a number of best practices<br />
from around the world that can be adapted to and<br />
replicated in other contexts. They range from El<br />
Salvador’s National <strong>Health</strong> Forum to the<br />
Development Observatory in Mozambique and<br />
Nepal’s data collection system, which provides data<br />
disaggregated by sex, age, caste, ethnicity and<br />
regional identity.<br />
Ensuring the meaningful participation of civil<br />
society in policy and planning is not easy, not least<br />
due to the immense diversity inherent in the<br />
concept of civil society. Nevertheless, where there<br />
is strong political will, practical obstacles can be<br />
overcome and the fruits of accelerated and<br />
improved development can be shared.<br />
BacKground &<br />
introduction<br />
Ownership is the first of the five principles set out in<br />
the Paris Declaration on Aid Effectiveness. It is<br />
important to note that the concept of democratic<br />
ownership of development processes by partner<br />
countries is not limited to partner governments.<br />
Instead, it involves other key players in a<br />
democratic system, particularly ‘domestic<br />
accountability stakeholders’ such as civil society<br />
and parliamentarians. However, in practice, the<br />
principle of ‘country’ ownership is all too often<br />
interpreted narrowly as ‘government’ ownership,<br />
driven by the priorities of the Ministry of Finance.<br />
Broad-based democratic ownership requires<br />
participation by all stakeholders, including civil<br />
society, the media, communities, service providers,<br />
parliament, line ministries and local level<br />
governance structures 1 .<br />
The Task Team on <strong>Health</strong> as a Tracer Sector is an<br />
in<strong>for</strong>mal international health <strong>for</strong>um which includes<br />
specialists in aid effectiveness and health from<br />
multilateral institutions, bilateral development<br />
agencies, developing countries and NGOs. Its<br />
mandate is to provide the Working Party on Aid<br />
Effectiveness with concrete illustrations of progress<br />
and remaining bottlenecks in the implementation of<br />
the Paris Declaration and Accra Agenda <strong>for</strong> <strong>Action</strong><br />
in the health sector 2 . Its findings on progress in aid<br />
effectiveness, including on democratic ownership,<br />
will feed into discussions at the Fourth High-Level<br />
Forum on Aid Effectiveness to be held in Busan,<br />
South Korea, from 29 November to 1 December<br />
2011. A final report will be released, focusing on<br />
progress in implementing the Paris Declaration<br />
principles and particularly highlighting country<br />
situations 3 .<br />
Photograph: DSW<br />
1 See OECD/DAC (2008)<br />
2 See OECD website http://www.oecd.org/document/55/0,3746,en_2649_3236398_42070263_1_1_1_1,00.html<br />
3 Other discussions will concentrate on the contribution of aid effectiveness to achieve better results in health, analysis of the role of China, Brazil, India and<br />
Russia in the health sector in partner countries and the role of aid in supporting the effective contribution of the private sector in the sub-Saharan African<br />
health sector (OECD website).
aid effectiveness<br />
5<br />
aim & methodology<br />
The aim of this report is to contribute to the debate<br />
in the lead-up to the Fourth High-Level Forum on<br />
Aid Effectiveness; to provide lessons learned and<br />
models <strong>for</strong> best practice, particularly in the health<br />
sector; and thus to influence donor and recipient<br />
governments, as well as civil society itself, to<br />
continue focusing on making democratic ownership<br />
of aid effectiveness a reality.<br />
This report was prepared following the review of a<br />
number of reports on health aid effectiveness,<br />
particularly those published by <strong>Action</strong> <strong>for</strong> <strong>Global</strong><br />
<strong>Health</strong> (AfGH) and the German Foundation <strong>for</strong><br />
World Population (DSW) 4 . Importantly, it is based<br />
on 14 interviews in El Salvador, Mozambique and<br />
Nepal, the findings of which complemented<br />
AfGH/DSW country reports <strong>for</strong> El Salvador and<br />
Mozambique, and an AfGH report – as well as the<br />
author’s personal experience – on aid effectiveness<br />
in Nepal respectively. It also draws on the most<br />
recently published IHP+ Results study 5 as well as<br />
the Join Assessment National Strategy (JANS)<br />
reports from Ethiopia, Ghana, Uganda and Vietnam<br />
and a few other websites and documents .<br />
After providing an overview of the concept and<br />
benefits of civil society participation, the report<br />
presents the principle of country ownership as<br />
stipulated in the Paris Declaration and refined in<br />
the Accra Agenda <strong>for</strong> <strong>Action</strong>. In a second part, El<br />
Salvador, Mozambique and Nepal are presented as<br />
case studies and civil society participation in these<br />
countries is analysed in light of achievements,<br />
challenges and lessons learned. This section also<br />
provides an overview of best practice examples<br />
from El Salvador, Mozambique, Nepal and a few<br />
other countries. A conclusive section compares the<br />
three case studies and draws parallels and<br />
conclusions of significance to developing countries<br />
more generally. Recommendations <strong>for</strong> the<br />
improvement of civil society participation and<br />
democratic ownership are made at the end.<br />
part 1: cso<br />
participation in<br />
improving aid<br />
effectiveness<br />
definition of civil society<br />
Civil society has been defined in various ways,<br />
reflecting the real diversity of civil society<br />
organisations (CSOs) and also hinting at the<br />
difficulties in providing a comprehensive yet<br />
specific and useful definition.<br />
Some key questions and areas of debate make<br />
defining the term civil society a challenge and have<br />
practical implications on aid effectiveness. For<br />
example, donors and recipient governments are<br />
often reluctant to recognise the role that civil<br />
society actors, including community-based<br />
organisations (CBOs), can play in national policy<br />
making. At the same time, many donors and<br />
recipient governments have begun to recognise<br />
that civil society actors have a legitimate role to<br />
play in the design and implementation of country<br />
health plans and in holding all partners accountable<br />
<strong>for</strong> delivering results, thus contributing to improved<br />
health outcomes. Another key issue is the lack of<br />
clarity about who represents whom within the<br />
development community. The main challenge in<br />
this regard is how to effectively widen and enhance<br />
engagement of civil society actors at the country<br />
level so as to ensure their meaningful contribution<br />
to the development of country health plans.<br />
The definition of civil society provided by the<br />
London School of Economics’ Centre <strong>for</strong> Civil<br />
Society Studies illustrates the many complexities of<br />
the concept and highlights the gaps between<br />
aspirations and reality:<br />
“Civil society refers to the arena of uncoerced<br />
collective action around shared interests, purposes<br />
and values. In theory, its institutional <strong>for</strong>ms are<br />
distinct from those of the state, family and market,<br />
though in practice, the boundaries between state,<br />
civil society, family and market are often complex,<br />
blurred and negotiated. Civil society commonly<br />
embraces a diversity of spaces, actors and<br />
institutional <strong>for</strong>ms, varying in their degree of<br />
<strong>for</strong>mality, autonomy and power […]”.<br />
4 Reports are available at www.action<strong>for</strong>globalhealth.eu and www.dsw-brussels.org<br />
5 See website http://www.ihpresult.net
6 aid effectiveness<br />
A more concise and practical definition is provided<br />
by a recent AfGH report, which defines civil society<br />
as “the actors that <strong>for</strong>m an interface between<br />
citizens and their government, including registered<br />
charities, community groups, trade unions, and<br />
faith-based organisations” 6 . This report focuses on<br />
civil society organisations of all sizes and shapes in<br />
the global ‘South’ and uses the AfGH definition of<br />
civil society.<br />
why is civil society participation<br />
important<br />
There are a number of reasons why civil society<br />
participation in development processes is<br />
important. Ensu ring a voice <strong>for</strong> those that<br />
development processes are supposed to benefit, ie<br />
the clients of development, is an end in itself.<br />
Furthermore, involving civil society can improve aid<br />
effectiveness in a number of ways:<br />
■ The perspectives of communities and<br />
vulnerable groups are brought to the table first<br />
hand, rather than through an extensive range of<br />
intermediaries.<br />
■ CSOs have access to the most vulnerable,<br />
marginalised and difficult-to-reach populations<br />
and are thus able to represent interests that are<br />
all too easily ignored otherwise.<br />
■ Civil society groups can contribute to enhancing<br />
government accountability and transparency by<br />
acting as a watchdog in accountability<br />
mechanisms.<br />
■ Civil society can hold donors to account <strong>for</strong> the<br />
effective utilisation of development aid.<br />
■ Civil society can bring recipient governments,<br />
donors and communities together, thus<br />
supporting open discussion and greater political<br />
engagement.<br />
■ The principle of democracy requires a system<br />
that allows <strong>for</strong> checks and balances. These can<br />
be provided by a variety of actors, including<br />
parliaments, civil society, the media, and others.<br />
■ CSOs are important service providers in the<br />
health sector and thus ‘implementers’ of aid,<br />
particularly in marginalised and remote areas.<br />
■ CSOs can build “in<strong>for</strong>med public opinion on<br />
health and shift social attitudes” 8 .<br />
■ CSOs contribute to raising and increasing<br />
awareness and knowledge about citizens’ rights<br />
and other human rights.<br />
Civil society has a long history of engagement in<br />
the health sector, particularly where government<br />
action was lacking. The 1978 Alma-Ata Declaration<br />
was a landmark <strong>for</strong> recognising people’s<br />
participation in health systems as central to primary<br />
healthcare and <strong>for</strong> acknowledging the role that<br />
organised social action plays in improving health<br />
outcomes. In many developing countries today, a<br />
significant proportion of healthcare is delivered by<br />
civil society, including non-governmental<br />
organisations (NGOs) and community-based<br />
organisations (CBOs). For example, in Cambodia<br />
30 to 40% of routine immunisation is delivered by<br />
CSOs. The figure rises to 40% <strong>for</strong> Ghana, Uganda<br />
and Tanzania and as high as 45 to 65% in Northern<br />
Kenya 9 .<br />
■ National health strategies and plans benefit<br />
from the beneficiaries’ perspective and thus<br />
become more appropriate, realistic and<br />
effective.<br />
■ Community participation in programme design<br />
and decision making may play a significant role<br />
in meeting the Millenium Development Goals<br />
(MDGs) 7 .<br />
Photograph: DSW<br />
6 AfGH 2011<br />
7 See <strong>for</strong> example AfGH 2011 citing S. Commins, Community participation in Service Delivery and Accountability, 2007. See also WHO, Strategic Alliances:<br />
The role of civil society in health, 2001.<br />
8 AfGH 2011<br />
9 Bass 2006
aid effectiveness<br />
7<br />
what was agreed in paris and accra<br />
Ownership is the first of five principles set out in the<br />
2005 Paris Declaration on Aid Effectiveness that<br />
was signed by almost all OECD/DAC donors and<br />
over 60 governments from developing countries 10 .<br />
Its text is outlined in the box below:<br />
ownership: partner countries<br />
eXercise effective leadership over<br />
their development policies and<br />
strategies and coordinate<br />
development actions.<br />
Partner countries commit to:<br />
■ exercise leadership in developing and<br />
implementing their national development<br />
strategies through broad consultative<br />
processes<br />
■ translate these national development<br />
strategies into prioritised results-oriented<br />
operational programmes as expressed in<br />
medium-term expenditure frameworks and<br />
annual budgets<br />
■ take the lead in co-ordinating aid at all levels<br />
in conjunction with other development<br />
resources in dialogue with donors and<br />
encouraging the participation of civil society<br />
and the private sector.<br />
Donors commit to:<br />
■ respect partner country leadership and help<br />
strengthen their capacity to exercise it.<br />
The Paris Declaration very explicitly demanded<br />
“broad consultative processes” in the <strong>for</strong>mulation of<br />
national development strategies and called on<br />
governments to not only enter into a dialogue with<br />
donors, but to encourage the participation of civil<br />
society as well.<br />
In the 2008 Accra Agenda <strong>for</strong> <strong>Action</strong> to accelerate<br />
and deepen implementation of the Paris<br />
Declaration, the following statement was included<br />
to demonstrate the importance and elaborate on<br />
the principle of ownership, widening it even more<br />
explicitly towards a concept of broad-based<br />
democratic ownership that emphasises the<br />
participation of parliamentarians, civil society and<br />
other actors:<br />
strengthening country ownership<br />
Developing countries determine and implement<br />
their development policies to achieve their own<br />
economic, social and environmental goals. We<br />
agreed in the Paris Declaration that this would<br />
be our first priority. Today, we are taking<br />
additional steps to turn this resolution into a<br />
reality.<br />
we will Broaden country-level<br />
policy dialogue on development<br />
We will engage in open and inclusive dialogue<br />
on development policies. We acknowledge the<br />
critical role and responsibility of parliaments in<br />
ensuring country ownership of development<br />
processes. To further this objective we will take<br />
the following actions:<br />
■ Developing country governments will work<br />
more closely with parliaments and local<br />
authorities in preparing, implementing and<br />
monitoring national development policies<br />
and plans. They will also engage with civil<br />
society organisations (CSOs).<br />
■ Donors will support ef<strong>for</strong>ts to increase the<br />
capacity of all development actors –<br />
parliaments, central and local governments,<br />
CSOs, research institutes, media and the<br />
private sector – to take an active role in<br />
dialogue on development policy and on the<br />
role of aid in contributing to countries’<br />
development objectives.<br />
■ Developing countries and donors will ensure<br />
that their respective development policies<br />
and programmes are designed and<br />
implemented in ways consistent with their<br />
agreed international commitments on<br />
gender equality, human rights, disability and<br />
environmental sustainability.<br />
we will deepen our engagement with<br />
civil society organisations<br />
We will deepen our engagement with CSOs as<br />
independent development actors in their own<br />
right whose ef<strong>for</strong>ts complement those of<br />
governments and the private sector. We share<br />
an interest in ensuring that CSO contributions<br />
to development reach their full potential. To this<br />
end:<br />
■ We invite CSOs to reflect on how they can<br />
apply the Paris principles of aid<br />
effectiveness from a CSO perspective.<br />
10 For list of signatories as well as full text of Paris Declaration and Accra Agenda <strong>for</strong> <strong>Action</strong> see OECD website.
8 aid effectiveness<br />
■ We welcome the CSOs’ proposal to engage<br />
with them in a CSO-led multi-stakeholder<br />
process to promote CSO development<br />
effectiveness. As part of that process, we<br />
will seek to i) improve coordination of CSO<br />
ef<strong>for</strong>ts with government programmes, ii)<br />
enhance CSO accountability <strong>for</strong> results, and<br />
iii) improve in<strong>for</strong>mation on CSO activities.<br />
■ We will work with CSOs to provide an<br />
enabling environment that maximises their<br />
contributions to development.<br />
In other words, a significant step towards further<br />
emphasising the importance of civil society<br />
engagement in aid and policy processes was taken<br />
during the Third High-Level Forum in Accra. The<br />
acknowledgment that civil society actors have a<br />
legitimate role to play in the design and<br />
implementation of country health plans and in<br />
holding all partners accountable <strong>for</strong> delivering<br />
results and achieving improved health outcomes<br />
had been necessary. Donors pledged support<br />
through strengthening the capacity of developing<br />
countries to exercise leadership and <strong>for</strong> CSOs to<br />
play an active role as “independent development<br />
actors in their own right”.<br />
recent developments<br />
The European Commission is in the process of<br />
developing a Communication on meaningful<br />
engagement of civil society in decision-making<br />
processes and drafting new guidelines on policy<br />
dialogue in the health sector, including a chapter on<br />
inclusive leadership. The aim of these Guidelines<br />
on Policy Dialogue on <strong>Global</strong> <strong>Health</strong> is to provide<br />
officials and representatives of the EU with the<br />
in<strong>for</strong>mation and knowledge they need to establish<br />
regional, national and international dialogue and<br />
political negotiations, which respects and promotes<br />
“values” agreed by the EU and Member States on<br />
global health 11 . However, the process has suffered<br />
from significant gaps in transparency so far and<br />
CSOs have not been in<strong>for</strong>med on how to<br />
participate.<br />
part 2: case study<br />
analysis &<br />
comparison Between<br />
el salvador,<br />
mozamBique & nepal<br />
This section introduces and analyses civil society<br />
participation in health policy processes in El<br />
Salvador, Mozambique and Nepal. After providing<br />
an overview of the health policy environment in<br />
each country, achievements, challenges and<br />
lessons learned are summarised.<br />
el salvador 12<br />
Classified as a middle-income country, El Salvador<br />
has seen aid flows decrease year on year since its<br />
return to democracy two decades ago. Overseas<br />
Development Assistance is now approximately<br />
1.7% of GDP and gradually declining. In this<br />
context, the Government recognises the<br />
importance of increasing aid effectiveness in order<br />
to make the best use of scarce resources. El<br />
Salvador only became a signatory of the Paris<br />
Declaration on Aid Effectiveness in 2009, shortly<br />
be<strong>for</strong>e a historic change in government, which<br />
ended the 17-year rule of the Nationalist<br />
Republican Alliance.<br />
The country’s new five-year development plan<br />
2010-2014 was launched in June 2010. Through<br />
this plan, the Government established 10 priority<br />
areas, including poverty reduction and the<br />
promotion of social participation in policy-making<br />
processes. It also establishes a 10-priority vision<br />
<strong>for</strong> 2024. Until recently, El Salvador’s health sector<br />
had been characterised by severe fragmentation:<br />
instead of a single strategic framework there were<br />
a range of health programmes with little or no<br />
coherence between them. The Ministry of <strong>Health</strong>’s<br />
organisational structure also reflected this<br />
fragmentation.<br />
Photograph: DSW<br />
11 AfGH 2011<br />
12 This section is based on interviews with civil society representatives conducted in 2011 and draws heavily from the AfGH/DSW report on El Salvador.
aid effectiveness<br />
9<br />
On paper, the new government has committed to<br />
establishing strong mechanisms <strong>for</strong> non-state actor<br />
participation. A National Policy <strong>for</strong> Social<br />
Participation in the <strong>Health</strong> Sector was elaborated in<br />
2009. However, the policy has not yet come into<br />
<strong>for</strong>ce. Nevertheless, a number of participatory<br />
mechanisms were created or strengthened over<br />
the last few years. For example, an intersectoral<br />
committee (CISALUD), made up of government<br />
representatives, civil society and other key<br />
stakeholders, was established as a consultative<br />
entity <strong>for</strong> policy-making processes.<br />
Among other areas relevant to citizen participation<br />
in health, the Government’s health policy <strong>for</strong> 2009-<br />
2014 includes the creation of a National <strong>Health</strong><br />
Forum (FNS) <strong>for</strong> the purpose of making<br />
consensus-based decisions in the development of<br />
a national health system based on the right to<br />
health, universal coverage, inclusion, quality and<br />
civic engagement. The Forum was established in<br />
May 2010 when 3,000 participants from around the<br />
country came together in the capital to discuss the<br />
topic “Building Social Participation in <strong>Health</strong>” 13 . By<br />
acting as an open plat<strong>for</strong>m <strong>for</strong> all non-state actors<br />
working on health, the Forum seeks to overcome<br />
the high degree of civil society fragmentation and<br />
polarisation around party affiliation. The Forum’s<br />
structure is based on a national Organising<br />
Committee and a permanent sub-national structure<br />
to facilitate its activities. A Ministry of <strong>Health</strong> (MoH)<br />
representative interviewed by DSW <strong>for</strong> its report on<br />
aid effectiveness in El Salvador stated that they<br />
would like to see the consultation of this entity<br />
become a mandatory precondition <strong>for</strong> establishing<br />
new policies in the health sector, thus ensuring that<br />
non-state actors can effectively carry out their<br />
policy watchdog role. However, clear terms of<br />
reference, membership adherence rules, as well as<br />
working procedures and consultation rules are yet<br />
to be established.<br />
achievements<br />
■ A document entitled "Commitments <strong>for</strong> a<br />
National Agenda on Aid Effectiveness" contains<br />
a series of agreements <strong>for</strong> the implementation<br />
of the principles of the Paris Declaration and<br />
the Agenda <strong>for</strong> Accra <strong>Action</strong> in El Salvador. This<br />
document was developed following several<br />
days of consultation with different actors,<br />
including government institutions, civil society,<br />
international NGOs and development partners.<br />
■ Civil society participated in a broad consultative<br />
process in the development of the national<br />
health policy. It is felt that the final document<br />
“Building Hope” adequately reflects the<br />
positions of civil society. CSO positions were<br />
also reflected in the national drug policy, the<br />
draft law on medicines and the plan <strong>for</strong> health<br />
re<strong>for</strong>m.<br />
■ The National <strong>Health</strong> Forum has a solid structure<br />
<strong>for</strong> sub-national representation, with municipal<br />
Forum committees in each of the 262<br />
municipalities. Organisations participating in the<br />
national Forum prepare well, including through<br />
consultations of their constituencies. As a<br />
result, participating organisations feel well<br />
represented and believe they are able to make<br />
a difference.<br />
■ Good relationships between CSOs and local<br />
authorities result in a number of successful joint<br />
initiatives, such as the Joint Initiative <strong>for</strong> the<br />
Elaboration of Municipal Policies <strong>for</strong> the Rights<br />
of Girls, Children, Adolescents and Young<br />
Adults; and the Municipal Regulation <strong>for</strong><br />
Breastfeeding.<br />
■ Many CSOs participate in some <strong>for</strong>m of donorfunded<br />
advocacy or leadership training related<br />
to their area of expertise, thus strengthening<br />
their ability to participate in multi-stakeholder<br />
processes. In general, these trainings receive<br />
positive evaluations.<br />
■ The MoH recently established a mechanism on<br />
its website, where citizens who feel that their<br />
right to health has been violated can post their<br />
complaints 14 . The effectiveness of this<br />
mechanism remains to be seen.<br />
challenges<br />
■ Civil society is fragmented and polarised along<br />
lines of political affiliation. While the National<br />
<strong>Health</strong> Forum can absorb some of the resulting<br />
friction, this is an issue that needs to be actively<br />
and continuously considered by government,<br />
donors and civil society itself.<br />
■ Consultative processes, both those led by the<br />
Government and those led by donors, generally<br />
tend to involve the ‘usual suspects’ rather than<br />
a broader range of civil society. For example,<br />
the EU Delegation claims that it regularly<br />
consults civil society regarding country<br />
strategies and thematic projects, but civil<br />
society representatives deny having been<br />
involved. This indicates a lack of diversity in<br />
actors consulted 15 .<br />
13 See www.phmovement.org/en/node/2917 <strong>for</strong> more in<strong>for</strong>mation.<br />
14 See www.salud.gob.sv<br />
15 See AfGH/DSW report on El Salvador
10 aid effectiveness<br />
■ MoH staff members are widely seen as being<br />
opposed to civil society participation. Many<br />
CSOs believe that government officials see civil<br />
society as a threat to their status and, as a<br />
result, “do not have the slightest interest” in<br />
working with civil society 16 . Rivalry between the<br />
MoH and CSOs in the area of service delivery<br />
is seen by some as a consequence of<br />
conditionality imposed by the World Bank<br />
wanting to push <strong>for</strong> a more prominent role <strong>for</strong><br />
CSOs.<br />
■ A lack of recognition of the added value that<br />
CSOs can bring to policy-making processes is<br />
another key challenge. Moreover, there is little<br />
confidence in public institutions, which creates<br />
distrust and lack of interest in active<br />
participation on behalf of civil society.<br />
■ Both donors and the Government treat<br />
International NGOs (INGOs), local NGOs and<br />
CBOs very differently. This has many practical<br />
implications, including on resource allocation,<br />
in<strong>for</strong>mation provision and involvement in<br />
consultation processes. CBOs still tend to be<br />
excluded from many of these processes and<br />
are not seen as equal partners.<br />
■ None of the interviewed people feel that civil<br />
society has access to in<strong>for</strong>mation regarding aid.<br />
A lack of transparency about government<br />
consultation processes and uncertainty about<br />
possibilities <strong>for</strong> civil society to get involved in<br />
budgetary scrutiny of public expenditures may<br />
not only compromise the ability of civil society<br />
to engage in any meaningful way but also<br />
contribute to distrust vis-à-vis the<br />
Government 17 .<br />
lessons learned and<br />
recommendations<br />
■ Unifying civil society ef<strong>for</strong>ts and working<br />
towards greater motivation and involvement of<br />
community organisations across the country is<br />
key, and it is possible as shown by the success<br />
of the National <strong>Health</strong> Forum. Nevertheless,<br />
more ef<strong>for</strong>ts need to be made to improve and<br />
strengthen the relationship between INGOs,<br />
local NGOs, CBOs, local authorities and<br />
parliamentarians to improve their work as<br />
alliances. Donors should there<strong>for</strong>e actively seek<br />
to support partnership building among civil<br />
society.<br />
■ As proposed by a MoH representative,<br />
endorsement by the National <strong>Health</strong> Forum of<br />
new policies and plans should be made an<br />
integral part of the policy process and a<br />
mandatory pre-condition <strong>for</strong> finalisation of any<br />
health-related policy and plan.<br />
■ Rather than waiting <strong>for</strong> donors to offer support<br />
<strong>for</strong> certain activities, such as advocacy and<br />
policy-related capacity building, CSOs must be<br />
proactive in encouraging donors to put<br />
advocacy capacity building on their agenda.<br />
■ The relationship between government and NGO<br />
healthcare providers should be pushed towards<br />
one characterised by collaboration and<br />
complementarity, rather than competition and<br />
rivalry. Donors may facilitate this process by<br />
emphasising the importance of CSOs as<br />
service providers, particularly in bringing<br />
healthcare to remote areas and marginalised<br />
populations, in their regular policy dialogue with<br />
government.<br />
mozambique 18<br />
Mozambique’s Five-Year Development Plan 2010-<br />
2014 launched in early 2010 mentions improving<br />
access to basic social services including health,<br />
particularly <strong>for</strong> rural populations, as a priority.<br />
Mozambique’s health policy framework is<br />
articulated in several documents, including the<br />
<strong>Health</strong> Sector Strategic Plan 2007-2012 (PESS).<br />
Stated cornerstones of the policy are primary<br />
healthcare, equity and better quality of care. The<br />
Government’s Plan mentions strengthening of civil<br />
society participation as a key priority <strong>for</strong> the coming<br />
years. Civil society involvement has seen some<br />
improvement in Mozambique over the last<br />
decades. To a certain extent, this is due to<br />
demands by donors who encouraged the<br />
Government to, in turn, encourage civil society<br />
participation in planning processes.<br />
The 2010 share of external funding within the<br />
national health budget is around 44%, down from<br />
73% in 2008 19 . In other words, aid is a major<br />
contributor to the health sector, particularly in the<br />
areas of infrastructure, human resources and drug<br />
supply. Interviewees feel that the quality of and<br />
access to primary healthcare has improved as a<br />
result of donor support.<br />
Multi-stakeholder Development Observatories at<br />
both national and provincial levels represent civil<br />
society's views on government policy and action.<br />
The national-level Observatory is a multi-sectoral<br />
body composed of representatives of the<br />
16 Interview with Margarita Posada, Coordinator of the National <strong>Health</strong> Forum and also representing the Citizens’ Alliance Against Privatisation of <strong>Health</strong>.<br />
17 It should be mentioned that poor access to in<strong>for</strong>mation is partly due to in<strong>for</strong>mation systems being weak, thus making access to solid in<strong>for</strong>mation difficult <strong>for</strong><br />
all actors involved.<br />
18 This section is based on interviews conducted with civil society representatives in Mozambique and draws heavily from the AfGH/DSW report on aid<br />
effectiveness in Mozambique.<br />
19 The main reason <strong>for</strong> this decrease is the fact that funds provided by the <strong>Global</strong> Fund were recently taken off budget after having been on budget <strong>for</strong> many<br />
years.
aid effectiveness<br />
11<br />
Government, the donor community and civil<br />
society. Civil society is represented through a group<br />
called the G20, which includes churches, labour<br />
unions, national and international NGOs, the<br />
private sector and academics. Recommendations<br />
emerging from the Development Observatory are<br />
part of the annual aid review. Launched in 2003 as<br />
a government initiative to establish a permanent<br />
mechanism <strong>for</strong> hearing the concerns and<br />
aspirations of CSOs, the then-called Poverty<br />
Observatory gradually expanded to the provinces,<br />
and in 2008 <strong>for</strong> the first time meetings were held in<br />
all provincial capitals 20 . Overall, the Observatory<br />
story is one of success:<br />
“The participation of CSOs in the consultations is<br />
positive and increasingly more active and better<br />
in<strong>for</strong>med. The interaction between government and<br />
CSOs is good and as a number of CSOs are<br />
becoming more involved in monitoring policy<br />
implementation at different levels, their contribution<br />
is more and more based on evidence.” 21<br />
However, there is no health coordination<br />
mechanism that systematically, ie <strong>for</strong>mally and<br />
regularly, involves civil society. Nevertheless, two of<br />
the most prominent NGO plat<strong>for</strong>ms in<br />
Mozambique, the Mozambican Network of <strong>AID</strong>S<br />
Services Organisation (MONASO) and NAIMA<br />
(<strong>AID</strong>S Impact Mitigation Association) have been<br />
able to regularly participate in <strong>Health</strong> Sector Wide<br />
Approach (SWAp) processes, such as the SWAp<br />
Forum, various working groups, and the<br />
elaboration of the <strong>Health</strong> Strategic Plan. However,<br />
these groups claim that their participation has not<br />
been sufficiently meaningful and follow-up to their<br />
recommendations has been lacking.<br />
achievements<br />
■ The Development Observatories process allows<br />
<strong>for</strong> systematic engagement of civil society and<br />
has led to civil society views and concerns with<br />
health policies being reflected.<br />
■ Since its expansion to regional capitals in 2008,<br />
the Development Observatory mechanism<br />
allows <strong>for</strong> adequate regional participation in<br />
consultative and decision-making processes.<br />
■ While there is certainly room <strong>for</strong> improvement,<br />
health policies today tend to be more inclusive<br />
of stakeholder views and gradually take into<br />
account community needs. This is also partly<br />
due to improved capacity of CSOs to monitor<br />
policy implementation at community level and<br />
feed community needs back into the planning<br />
process.<br />
■ Individual networks and organisations make<br />
serious ef<strong>for</strong>ts at representation: MONASO, <strong>for</strong><br />
example, has representatives in all provinces<br />
and in all districts where its members work.<br />
District-level concerns are represented in<br />
regular province-level meetings, and elected<br />
representatives from the provinces represent<br />
members at the national level. Representatives<br />
at regional and national level have three- and<br />
five-year mandates respectively. The provincial<br />
and national General Assembly are seen as<br />
accountability mechanisms <strong>for</strong> members to<br />
recur to as necessary.<br />
■ Some donors, such as the European<br />
Commission, have agreements with the<br />
Government that underpin a shared<br />
responsibility <strong>for</strong> CSO involvement: The<br />
Cotonou agreement, upon which the EU’s<br />
Memorandum of Understanding (MoU) with<br />
Mozambique is based, specifically recognises<br />
local authorities, parliaments and non-state<br />
actors as partners in development.<br />
■ The Civil Society Support Mechanism (CSSM),<br />
a five-year programme initiated by the UK’s<br />
Department <strong>for</strong> International Development<br />
(DFID) and Irish Aid, aims to improve<br />
governance and accountability <strong>for</strong> ordinary<br />
Mozambican citizens. This is undertaken by<br />
strengthening and diversifying the engagement<br />
of Mozambican CSOs through governance<br />
monitoring and advocacy. The CSSM provides<br />
capacity building and grants in the areas of<br />
governance monitoring and advocacy <strong>for</strong> CSOs<br />
that have innovative, feasible and relevant<br />
project ideas.<br />
■ While many CSOs still find it difficult to access<br />
in<strong>for</strong>mation concerning aid, most respondents<br />
feel that the IHP+ has created more space <strong>for</strong><br />
civil society to engage, especially in passing on<br />
in<strong>for</strong>mation about the health sector. This<br />
facilitates engagement in national and regional<br />
policy processes.<br />
challenges<br />
■ Civil society is not involved in the Coordination<br />
Committee, said to be Mozambique’s most<br />
influential <strong>for</strong>um on health and health policy<br />
development. The Coordination Committee<br />
brings together the Ministry of <strong>Health</strong> and<br />
development partners and meets twice a year.<br />
Decisions made in these meetings feed into the<br />
Ministry’s planning process.<br />
■ CSO networks that get to participate in<br />
consultation processes are not necessarily<br />
representative of civil society. For example, the<br />
two groups that appear to be invited to all key<br />
20 For more in<strong>for</strong>mation see http://www.undp.org.mz/en/What-we-do/Poverty-and-HIV-<strong>AID</strong>S/Press-Releases/Development-Observatories-as-Potential-<br />
Citizenship-Fora<br />
21 Interview with Rosalia Mutisse, Project Officer at HelpAge International.
12 aid effectiveness<br />
national-level consultation processes are<br />
plat<strong>for</strong>ms focusing on HIV and <strong>AID</strong>S and sexual<br />
and reproductive health, ie on issues that are<br />
favoured by donors and thus receive relatively<br />
large amounts of funding. CSOs working on<br />
other health issues often do not receive as<br />
much funding and cannot establish powerful<br />
advocacy plat<strong>for</strong>ms. Consequently, they are not<br />
in the spotlight and not invited <strong>for</strong> consultation.<br />
■ Some believe that the Government involves<br />
only those CSOs in consultation processes that<br />
are seen to be on its side from a political point<br />
of view. This creates tension among<br />
organisations with different political affiliations<br />
within major CSO plat<strong>for</strong>ms.<br />
■ Donors, in their individual consultation<br />
processes, are also guilty of continuously<br />
engaging the same few CSOs – which are<br />
typically large and based in the capital – instead<br />
of seriously aiming <strong>for</strong> representativeness. This<br />
is partly due to limited donor staff resources,<br />
which makes serious engagement with a<br />
representative range of civil society difficult.<br />
■ Size is another issue. The bigger CSO<br />
networks are, the more difficult it becomes <strong>for</strong><br />
their representatives to adequately reflect and<br />
defend civil society’s interests. For example,<br />
MONASO supposedly represents 1,400<br />
members in 102 districts. It admits that finding a<br />
common position, particularly on sensitive<br />
issues such as treatment <strong>for</strong> sexually<br />
transmitted diseases, remains a challenge.<br />
■ There have been reports of civil society<br />
representatives not making use of their<br />
opportunities <strong>for</strong> participation. While being<br />
physically present in consultations, some do not<br />
raise their voices at all. To what extent this is<br />
due to dismissive attitudes by government,<br />
which does seem to be an issue, or other<br />
factors, remains unclear.<br />
■ Rivalry and distrust between CSOs and<br />
government are barriers to open dialogue and<br />
negotiation. In many cases, government staff<br />
feel threatened by the active participation of<br />
civil representatives and as a result adopt<br />
defensive attitudes. Such attitudes mean that<br />
spaces created <strong>for</strong> CSO participation in the<br />
national health sector policies may not be made<br />
full use of and they may be one reason why civil<br />
society participation in joint <strong>for</strong>a is not always<br />
very active.<br />
■ Many local CSOs lack the capacity to<br />
adequately confront government specialists in<br />
policy, planning and monitoring processes.<br />
However, CSO proposals to donors <strong>for</strong> capacity<br />
building support get turned down. There are<br />
several examples of CSOs, such as MONASO,<br />
submitting proposals <strong>for</strong> advocacy-capacity<br />
building to donors and being unsuccessful<br />
because the Government, to whom proposals<br />
get submitted in the process, does not approve,<br />
apparently due to a general distrust towards<br />
CSO advocacy work.<br />
lessons learned and<br />
recommendations<br />
■ In order to improve sub-national representation<br />
and strengthen the voice of communities, a<br />
number of measures can be taken: giving<br />
national CSOs space in meetings, organising<br />
internal consultations be<strong>for</strong>e attending key<br />
meetings with donors and government, and<br />
organising regular internal meetings at all<br />
levels. These suggestions by one respondent 22<br />
are ways <strong>for</strong> ensuring community concerns get<br />
transmitted to national level stakeholders.<br />
■ There is a need <strong>for</strong> donors and the Government<br />
to actively reach out to a greater diversity of<br />
CSOs in order to make consultation processes<br />
even more representative of Mozambican<br />
society. Moreover, partnership building between<br />
INGOs, CSOs and CBOs needs to be actively<br />
supported. Furthermore, rather than compete<br />
<strong>for</strong> funding and government attention, INGOs<br />
could focus on capacity building <strong>for</strong> local CSOs.<br />
■ Rather than seeing each other as rivals in<br />
regard to health service provision, NGOs and<br />
the Government should focus on their<br />
respective added value and thus ensure<br />
complementarity. CSOs’ ability to reach the<br />
most marginalised communities should be<br />
adequately valued by the Government as well<br />
as donors. An NGO service <strong>for</strong> HIV and <strong>AID</strong>S<br />
working in tandem with a local hospital in a rural<br />
district of Mozambique is a positive example of<br />
successful partnership and collaboration.<br />
■ There is a need <strong>for</strong> an open and transparent<br />
dialogue between CSOs and government<br />
officials, potentially facilitated by donors, to<br />
discuss and address issues around distrust<br />
between CSOs and the Government.<br />
■ Donors must identify ways to ensure those<br />
CSOs who want to apply <strong>for</strong> advocacy-related<br />
funding do not get discouraged, or rejected,<br />
because of a general ‘fear’ of advocacy by the<br />
Government. In other words, they must review<br />
their grant-making processes.<br />
■ A comprehensive and publicly available<br />
mapping of CSOs would be a first step in<br />
improving the diversity of civil society that<br />
participates in consultations, not least because<br />
it would allow development partners with limited<br />
staff to contact a wider range of more specific<br />
organisations relevant to geographic location<br />
and activity.<br />
22 Interview with Helder White, Programme Director at MONASO (Mozambique Network of <strong>AID</strong>S Service Organizations)
aid effectiveness<br />
13<br />
■ Monitoring the real use of the spaces created<br />
<strong>for</strong> civil society participation would likely provide<br />
important insights, since the degree of CSO<br />
participation depends, to a significant extent, on<br />
encouraging attitudes by individuals, whether<br />
systems <strong>for</strong> participation exist or not.<br />
nepal 23<br />
In 2007 Nepal introduced a Free <strong>Health</strong>care Policy<br />
that <strong>for</strong>esees universal free essential health<br />
services at health post and sub-health post levels.<br />
In 2009, a policy to make maternal health services<br />
free at the point of access was also introduced.<br />
Nepal’s <strong>Health</strong> Sector Programme Implementation<br />
Plan II was developed in 2010 <strong>for</strong> a period of five<br />
years. Despite clear equity gaps, child and<br />
maternal mortality have improved with increased<br />
access to healthcare:<br />
“The health situation of the country is improving.<br />
For example, maternal and neonatal mortality has<br />
decreased, life expectancy at birth has increased,<br />
immunisation coverage and institutional delivery<br />
have also increased. However, there is disparity<br />
between rural and urban, east and west and<br />
between different caste and ethnic groups.”<br />
Aid effectiveness has been slowly improving since<br />
the early 2000s, when health donors started getting<br />
together regularly in coordination meetings, and 11<br />
donors joined a health SWAp in 2004. Joint Annual<br />
Review meetings take place twice a year, bringing<br />
together donors, government and civil society<br />
under the leadership of the Ministry of <strong>Health</strong>. A<br />
June review normally focuses on planning and a<br />
November meeting on programmes. After every<br />
review an Aid Memoire is mutually agreed upon to<br />
guide coordinated work <strong>for</strong> the following six-month<br />
period. Partners are meant to prepare their<br />
organisational plans based on the outcomes of the<br />
reviews. An IHP+ compact was signed by eight<br />
partners in 2009.<br />
With almost 50% of health spending coming from<br />
aid, development assistance is crucial <strong>for</strong> Nepal.<br />
This ratio also means that it is difficult <strong>for</strong> the<br />
Government to maintain clear leadership. In<br />
addition, INGOs also channel substantial amounts<br />
of funding to the health sector at community level,<br />
representing yet another, important <strong>for</strong>ce. Nepal<br />
has a very diverse civil society, ranging from small,<br />
community-based groups and affected populations,<br />
to large INGOs, that are seen by many mainly as<br />
donors. There are 28,000 registered NGOs, but the<br />
total number of CSOs is estimated at around<br />
40,000; however, relatively speaking, not many<br />
seem to have an explicit focus on health.<br />
achievements<br />
■ Some CSOs do get involved fairly regularly and<br />
systematically in national-level consultations,<br />
such as Joint Annual Reviews. Consulting civil<br />
society in national development processes has<br />
become more frequent.<br />
■ Improvements in access to healthcare and<br />
special attention to the needs of marginalised<br />
groups in policy and budget provisions may be<br />
seen as “a direct result of participation in the<br />
decision-making process at national level” 25 .<br />
One respondent felt that the fact that Nepal’s<br />
Interim Constitution of 2007 pointed to people’s<br />
fundamental right to health was partly due to<br />
CSO influence. Similarly, introduction of free<br />
care is seen as an outcome of “proper<br />
cooperation and coordination among<br />
Government of Nepal, Development Partners<br />
and NGOs in Nepal” 26 .<br />
■ Data disaggregation facilitates the<br />
consideration and monitoring of community<br />
concerns. The Ministry of <strong>Health</strong> is piloting a<br />
data collection system which uses data<br />
disaggregated by sex, age, caste, ethnicity and<br />
regional identity. This will help monitor which<br />
groups benefit most from abolition of user fees<br />
and other health policies.<br />
■ Respondents feel that the IHP+ makes it easier<br />
<strong>for</strong> civil society to engage in national and<br />
regional policy processes because of its explicit<br />
focus on meaningful engagement of civil<br />
society.<br />
■ None of the respondents cited a general<br />
distrust of CSOs by the Government as an<br />
issue and one even pointed to the good<br />
relations between government and civil society.<br />
If valid, this can be seen as a great<br />
achievement, not least in light of earlier<br />
assessments that found a certain degree of<br />
polarisation due to political affiliation 27 .<br />
23 This section draws mainly on interviews, as well as an earlier case study by the author (AfGH 2009).<br />
24 Interview with Giridhari Sharma Paudel, Deputy Director General and Chief of Programme of National Family Planning Association.<br />
25 AfGH 2011<br />
26 Interview with Giridhari Sharma Paudel, Deputy Director General and Chief of Programme of National Family Planning Association.<br />
27 See AfGH 2009
14 aid effectiveness<br />
challenges<br />
■ CSO networks do not seem to make great<br />
ef<strong>for</strong>ts to adequately represent their members.<br />
Several interviewees stressed that membership<br />
in their respective organisation or network is not<br />
mandatory and based on mutual trust, which<br />
they seem to interpret as there not being a<br />
need <strong>for</strong> <strong>for</strong>mal ef<strong>for</strong>ts at representation.<br />
Networks tend to be seen as vehicles <strong>for</strong><br />
in<strong>for</strong>mation sharing and mutual support on the<br />
programme side rather than <strong>for</strong> political<br />
influence and representation.<br />
■ There are no systematic ef<strong>for</strong>ts at involving an<br />
adequate representation of civil society in the<br />
Joint Annual Reviews. In general, there do not<br />
seem to be any meaningful links between local,<br />
regional and national level civil society in terms<br />
of policy influence. However, many NGOs<br />
working in the districts have an office in the<br />
capital which could represent sub-national<br />
concerns.<br />
■ Some civil society representatives do not feel<br />
that <strong>for</strong>mal mechanisms that guarantee civil<br />
society a place around the policy making table<br />
are adequate: “Government can hire<br />
consultants and civil society members<br />
depending upon its need.” 28<br />
■ CSOs that do get invited to consultative<br />
processes tend to be representatives of large<br />
INGOs or other ‘usual suspects’ who have<br />
personal relationships with donors or<br />
government. One respondent maintained that<br />
“many donor organisations are supporting local<br />
CSOs based on their personal linkages and<br />
trust”. 29<br />
■ Despite the significance of aid in the health<br />
sector, in<strong>for</strong>mation on aid, or on how to collect<br />
aid-related in<strong>for</strong>mation, is not systematically<br />
made available. One interviewee mentioned<br />
that “in<strong>for</strong>mation regarding the aid provided to<br />
the Government by various donor<br />
organisations” is available, while in<strong>for</strong>mation on<br />
“aid provided to NGOs by different donor<br />
organisations is not”. 30<br />
■ Many CSOs see themselves as ‘supporters’<br />
and ‘assistants’ of government programming<br />
and policy, rather than as right holders in aid<br />
and development. Furthermore, while most<br />
stakeholders seem to agree that the non-state<br />
sector is vital to achieving the MDGs in Nepal,<br />
many view civil society as important only in the<br />
field of service delivery rather than in policy<br />
making.<br />
lessons learned and<br />
recommendations<br />
■ Donors who support civil society organisations<br />
and networks have an important role in<br />
encouraging better representation of subnational<br />
and community priorities and concerns<br />
and thus better reflection of the diversity of civil<br />
society. Donors are in an excellent position to<br />
build and strengthen a culture of representation<br />
due to their close engagement with some key<br />
NGOs and CSOs and because of the financial<br />
support they are able to provide.<br />
■ All development stakeholders have a<br />
responsibility to improve the confidence of<br />
CSOs towards a view that sees civil society as<br />
an equal partner to donors and the<br />
Government. While this view may be<br />
reasonably accepted when it comes to<br />
programming, it is decididly underdeveloped in<br />
regard to policy making and planning. Some<br />
CSOs feel that they can influence the national<br />
health plan by having their projects replicated<br />
and funded by the Government. While this is<br />
true to some extent, their ambitions in regard to<br />
policy influence need to be strengthened.<br />
■ CSOs that are not directly involved in the aid<br />
effectiveness agenda at national level may not<br />
have heard about the Paris principles, the Accra<br />
Agenda <strong>for</strong> <strong>Action</strong> or the International <strong>Health</strong><br />
Partnership. Nevertheless, they may still have<br />
important contributions to make about policy<br />
and aid effectiveness per se, as demonstrated<br />
in the interviews.<br />
other countries<br />
Largely speaking, the findings in El Salvador,<br />
Mozambique and Nepal are corroborated by<br />
research in other countries and contexts. This<br />
section presents selected findings from other<br />
reviews and assessments.<br />
In April 2011, the IHP+ Results per<strong>for</strong>mance report<br />
<strong>for</strong> 2010 was issued 31 . IHP+ Results is mandated to<br />
annually analyse the per<strong>for</strong>mance of each IHP+<br />
signatory individually as well as collectively, assess<br />
results at country level, and to report on whether<br />
commitments and expectations of the IHP+ are<br />
being achieved 32 . The 10 developing countries in its<br />
remit are: Burkina Faso, Burundi, Djibouti, DR<br />
Congo, Ethiopia, Mali, Mozambique, Nepal, Niger<br />
and Nigeria. In order to understand to what extent<br />
28 Interview with Bharat Pradhan, Executive Director of Public <strong>Health</strong> Concern Trust.<br />
29 idem<br />
30 Interview with Shanta Lall Mulmi, Executive Director of Resource Centre <strong>for</strong> Primary <strong>Health</strong>care.<br />
31 See References section <strong>for</strong> full details.<br />
32 The per<strong>for</strong>mance report reflects the findings <strong>for</strong> the second annual cycle of monitoring, undertaken in 2010. It builds on the findings of previous reviews and<br />
will in<strong>for</strong>m the third annual per<strong>for</strong>mance review in 2011.
aid effectiveness<br />
15<br />
civil society is bringing community perspectives into<br />
health policy processes and serves as watchdog<br />
<strong>for</strong> accountability, IHP+ Results reviewed:<br />
■ whether civil society has a seat at the health<br />
sector coordination mechanisms in each<br />
country 33<br />
■ whether development partners support civil<br />
society in engaging with these country<br />
mechanisms.<br />
Governments reported that civil society is<br />
represented in the health coordination mechanism<br />
in seven of the ten countries (all except Djibouti,<br />
Mozambique, and Nigeria). Civil society<br />
representation appeared to be increasing and had<br />
reached at least 10% of participants in countries’<br />
coordination mechanisms in Burundi, DR Congo,<br />
Ethiopia, Mali, Nepal and Niger. In Ethiopia and<br />
Mali civil society constituted 25 and 30% of the<br />
membership of the health sector coordination<br />
mechanism respectively. All development partners<br />
reported that they provide support <strong>for</strong> civil society<br />
participation in health policy processes.<br />
Nevertheless, the report stresses that further work<br />
is needed to tighten the definition of development<br />
partner ‘support’ to civil society.<br />
Overall, civil society representatives reported that<br />
their engagement in processes to develop national<br />
health plans was increasing. Civil society<br />
representatives becoming more engaged in<br />
national health sector planning processes be<strong>for</strong>e<br />
they become <strong>for</strong>mally represented in the country’s<br />
health sector coordination mechanism seems to be<br />
a typical pattern. Among a group of CSOs<br />
connected to the IHP+, most representatives<br />
reported that they were already participating in the<br />
development of national health plans and mutual<br />
accountability mechanisms. Some also reported<br />
making a contribution to and, to varying extents,<br />
influencing the outcomes of national Joint Annual<br />
<strong>Health</strong> Sector Reviews.<br />
These findings are encouraging, but it must be<br />
emphasised that those CSOs already linked up<br />
with the IHP+ are likely not sufficiently<br />
representative of civil society in these countries<br />
overall. In conclusion, despite observing some<br />
improvement, the report notes that “there is scope<br />
in most countries <strong>for</strong> further government<br />
engagement of their civil society, and <strong>for</strong> more<br />
development partner support <strong>for</strong> civil society, to<br />
become more meaningfully involved in broader<br />
health policy processes”.<br />
A report by AfGH 34 identifies the following major<br />
obstacles to meaningful civil society participation:<br />
■ suspicion and distrust towards CSOs by<br />
Ministry of <strong>Health</strong> staff<br />
■ skewed balance of power: CSO ‘partners’ are<br />
relied upon to deliver services but not seen as<br />
legitimate actors and equal partners in policy<br />
and planning<br />
■ lack of funding <strong>for</strong> local CSOs’ capacity building<br />
■ restriction of CSO roles and activities: in<br />
Zambia, <strong>for</strong> example, proposed legislation<br />
would require all CSOs to operate under threeyear<br />
licenses, making strategic planning and<br />
fundraising extremely challenging<br />
■ lack of transparency and serious consultation:<br />
in Uganda, parliamentarians only have one<br />
month to scrutinise the budget; in Mozambique<br />
and Zambia, health reports are not made<br />
available to parliament at all.<br />
Nevertheless, a number of Joint Assessment of<br />
National Strategies (JANS) find that civil society<br />
participation has been increasing and successfully<br />
influenced policy processes in several instances. In<br />
Ghana, <strong>for</strong> example, the joint assessment of the<br />
<strong>Health</strong> Sector Medium Term <strong>Health</strong> Plan 2010-<br />
2013 found that the Government had made a “good<br />
ef<strong>for</strong>t” to get inputs from a broad range of<br />
stakeholders, including civil society. Furthermore, a<br />
multi-sectoral Partners’ Forum that is led by the<br />
MoH meets monthly to discuss health-related<br />
issues. Besides senior MoH staff, this Forum<br />
includes development partners, faith-based<br />
organisations and other civil society<br />
representatives 35 .<br />
In Ethiopia, the JANS process provided a first-time<br />
opportunity <strong>for</strong> CSOs and NGOs to comment on<br />
Ethiopia’s National <strong>Health</strong> Sector Development<br />
Plan IV in an organised manner. Most civil society<br />
comments on the draft were reportedly included in<br />
the revised version. Moreover, CSOs and NGOs<br />
were given an additional opportunity to comment<br />
when the JANS steering committee, together with<br />
33 The health coordination mechanism is usually a government-led body comprising of domestic and international stakeholders in the health sector; it is not<br />
the <strong>Global</strong> Fund country coordination mechanism, but there may be overlaps.<br />
34 See AfGH 2011<br />
35 See IHP+ (2010) report on Ghana
16 aid effectiveness<br />
CSO umbrella organisations, arranged a workshop<br />
“to encourage and enable their optimum<br />
participation” 36 . In other words, JANS provided a<br />
mechanism <strong>for</strong> systematic engagement of CSOs<br />
that had not been involved in health policy making<br />
previously.<br />
While referring to civil society participation at times,<br />
the JANS report on Vietnam provides little<br />
in<strong>for</strong>mation on the extent and nature of civil society<br />
participation in the development of Vietnam’s fiveyear<br />
health plan 2011-2015. Nevertheless, it clearly<br />
states that civil society participation must be<br />
strengthened further 37 .<br />
eXamples of Best<br />
practice<br />
The following examples, many of which were<br />
introduced earlier, can be considered best practice<br />
worthy of being adapted or replicated in other<br />
contexts. It should be noted, nevertheless, that<br />
these mechanisms may also have weaknesses,<br />
particularly in relation to participation by CSOs and<br />
CBOs based outside major cities.<br />
Best practice of civil society<br />
participation around the world<br />
el salvador<br />
National<br />
<strong>Health</strong> Forum<br />
(FNS)<br />
ghana<br />
Partners’<br />
Forum<br />
36 See IHP+ (2011) report on Ethiopia<br />
37 See JANS Team 2011<br />
The Forum was designed as<br />
an open plat<strong>for</strong>m to unify the<br />
voices of a very diverse and<br />
fragmented civil society and<br />
to strengthen capacity of nonstate<br />
actors working on<br />
health. With FNS, municipal<br />
committees in each of the<br />
262 municipalities and a clear<br />
organisational structure,<br />
regional representation is<br />
possible.<br />
A Partners’ Forum led by the<br />
MoH meets monthly to<br />
discuss health-related issues.<br />
This Forum includes<br />
development partners, faithbased<br />
organisations and<br />
other civil society<br />
representatives besides<br />
senior MoH staff.<br />
mozambique<br />
Development<br />
Observatory<br />
nepal<br />
Data<br />
disaggregation<br />
tanzania<br />
Civil society<br />
support website<br />
Development Observatories<br />
at both national and<br />
provincial levels represent<br />
civil society's views on<br />
government policies and<br />
actions. Launched in 2003 as<br />
a government initiative to<br />
establish a permanent<br />
mechanism <strong>for</strong> hearing the<br />
concerns and aspirations of<br />
CSOs, the then Poverty<br />
Observatory gradually<br />
expanded to the provinces.<br />
The national-level<br />
Observatory is composed of<br />
representatives of the<br />
Government, the donor<br />
community and civil society.<br />
Civil society is represented<br />
through a group called the<br />
G20, which includes<br />
churches, labour unions,<br />
national and INGOs, the<br />
private sector and<br />
academics.<br />
Recommendations emerging<br />
from the Development<br />
Observatory are part of the<br />
annual aid review.<br />
Data disaggregation<br />
facilitates the consideration<br />
and monitoring of community<br />
concerns. The MoH is piloting<br />
a data collection system<br />
which uses data<br />
disaggregated by sex, age,<br />
caste, ethnicity and regional<br />
identity. This will help monitor<br />
which groups benefit most<br />
from abolition of user fees<br />
and other health policies.<br />
The EU Commission and<br />
Canada, with the contribution<br />
of all major donors in<br />
Tanzania, have established a<br />
civil society support website<br />
that contains and compares<br />
different funding opportunities<br />
<strong>for</strong> civil society, both <strong>for</strong><br />
advocacy and service<br />
delivery, by donor, sector and<br />
region<br />
(www.civilsocietysupport.net).
aid effectiveness<br />
17<br />
uganda<br />
global<br />
Independent<br />
Development<br />
Fund<br />
Inclusive and<br />
participatory<br />
development<br />
of national<br />
health<br />
strategy<br />
Uganda’s Independent<br />
Development Fund was set<br />
up to deliver a range of<br />
support services to Ugandan<br />
CSOs as a means of<br />
strengthening their capacities<br />
to effectively contribute to<br />
human and civil rights, good<br />
governance and poverty<br />
reduction. Supported by the<br />
Danish, Dutch, Irish, Swedish<br />
and UK governments through<br />
their development agencies,<br />
it is open almost exclusively<br />
<strong>for</strong> proposals from national<br />
CSOs and CBOs; INGOs can<br />
only apply as part of a<br />
consortium (www.idf.co.ug).<br />
A joint assessment revealed<br />
that the Government has<br />
made proactive ef<strong>for</strong>ts to<br />
ensure engagement of a<br />
broad range of non-state<br />
health actors in the<br />
development of Uganda’s<br />
<strong>Health</strong> Sector Strategic and<br />
Investment Plan 2010/11-<br />
2014/15. Sub-national<br />
engagement was also<br />
sought, and consultations<br />
were also held with districts<br />
and with other sectors and<br />
initiatives relevant to health.<br />
Civil society participation was<br />
found to be very vibrant and<br />
active and several<br />
consultations on the Plan<br />
were held and<br />
recommendations submitted.<br />
<strong>Global</strong> Fund<br />
country<br />
coordinating<br />
mechanism<br />
Civil society<br />
participation<br />
in IHP+<br />
Despite its limitations, the<br />
national coordinating<br />
mechanism of the <strong>Global</strong><br />
Fund is considered a best<br />
practice model <strong>for</strong> civil<br />
society and parliamentary<br />
engagement by many<br />
CSOs 38 . The Community<br />
Systems Strengthening<br />
Framework developed by the<br />
<strong>Global</strong> Fund in collaboration<br />
with the World <strong>Health</strong><br />
Organization (WHO),<br />
UN<strong>AID</strong>S and CSOs provides<br />
an important guidance on<br />
how to support civil society<br />
capacity-building activities<br />
and strengthen community<br />
systems.<br />
The IHP+ represents both<br />
Northern and Southern civil<br />
society in its global<br />
management structure. It has<br />
been shown that in countries<br />
where an IHP+ Compact is<br />
signed, civil society<br />
participation in decisionmaking<br />
processes<br />
increases 39 .<br />
<strong>Health</strong> Policy<br />
Advisory<br />
Committee<br />
The Committee is composed<br />
of representatives from the<br />
MoH and key donors,<br />
meeting on a regular basis in<br />
order to provide policy<br />
guidance to the sector. CSOs<br />
and members of parliament<br />
are invited to each annual<br />
health sector review in order<br />
to contribute to the<br />
discussions on past<br />
per<strong>for</strong>mance and future work.<br />
38 See <strong>for</strong> example AfGH/DSW (2010) report on Tanzania.<br />
39 See notes from the Third IHP+ Country <strong>Health</strong> Sector Teams Meeting, 9-10 December 2010, Brussels, Belgium. Available at:<br />
http://www.internationalhealthpartnership.net/en/news/display/3rd_ihp_country_teams_meeting
18 aid effectiveness<br />
part 3: cross-country<br />
comparisons &<br />
conclusions<br />
Inviting civil society to consultations on health<br />
policy has become fairly common, and it is fair to<br />
say that overall, both government and donors make<br />
active ef<strong>for</strong>ts to encourage and increase civil<br />
society engagement. However, donor and<br />
government partnerships with civil society as<br />
service providers are often confounded with civil<br />
society participation in advocacy. In other words,<br />
while CSOs play a significant and well-recognised<br />
role in service delivery in many countries, they<br />
often are excluded from policy-making processes.<br />
Moreover, without in-depth qualitative research it is<br />
very difficult to determine how meaningful even<br />
active participation of civil society in policy<br />
processes has been. Simply knowing that civil<br />
society ‘participated’ in a certain consultation does<br />
not provide in<strong>for</strong>mation on:<br />
■ who exactly participated, ie whether one or<br />
more civil society representatives participated,<br />
what part of civil society they represent,<br />
whether they are members of a large INGO or<br />
network, or belong to a small CBO, etc<br />
■ how actively civil society contributed, ie whether<br />
they contributed at all and in what manner<br />
■ whether civil society contributions were taken<br />
seriously by government and donors and<br />
provided space <strong>for</strong> discussion<br />
■ whether civil society recommendations were<br />
reflected in the final output, such as a policy or<br />
a plan.<br />
In order <strong>for</strong> civil society participation in national<br />
policy and planning processes to be meaningful, ie<br />
to respond to qualitative criteria as well as<br />
quantitative ones, political will of both donor and<br />
recipient governments is essential. In view of the<br />
immense diversity of civil society, meaningful<br />
participation is not easy to achieve. There<strong>for</strong>e,<br />
political will must be strong, serious and<br />
pronounced. In order to address some of the<br />
practical challenges, civil society, recipient<br />
governments and donors can learn from the best<br />
practices provided in this document and pick and<br />
adapt elements that are relevant to their respective<br />
country contexts.<br />
representation<br />
There are obvious challenges in managing and<br />
representing “what is a large and amorphous<br />
constituency” without losing a healthy diversity 40 .<br />
This is true both <strong>for</strong> regional, sectoral and structural<br />
representation. It must be noted that consulting all<br />
civil society, or even a representative sample, is not<br />
possible due to the enormous diversity, both<br />
organisatonally and sectorally. For example, in<br />
Nepal there are 28,000 registered NGOs and at<br />
least 10,000 CSOs that are unregistered 41 . In a<br />
population of 28 million this means that there is one<br />
registered NGO <strong>for</strong> every 1,000 people. There have<br />
been criticisms of some NGOs being set up<br />
exclusively as a money-making opportunity <strong>for</strong> their<br />
founders. Whatever the truth may be, this is not an<br />
excuse <strong>for</strong> consistently consulting the same few<br />
NGOs based in the capital that receive<br />
considerable international funding and thus speak<br />
an ‘international’ language.<br />
In some countries, such as El Salvador and<br />
Mozambique, extensive consultations within civil<br />
society are organised and there are processes at<br />
sub-national level that aim to approximate regional<br />
representation in national-level meetings. In El<br />
Salvador’s National <strong>Health</strong> Forum, in particular,<br />
substantial thought is given to appropriate<br />
reflection of the diversity of interests, and<br />
mechanisms are in place that approximate<br />
adequate representation. Furthermore, CSOs at<br />
regional and district level directly interact with local<br />
authorities, thus working through another important<br />
channel of influence. While Nepalese CSOs also<br />
interact with local authorities, none of the CSOs<br />
interviewed indicated that substantial or systematic<br />
ef<strong>for</strong>ts at representation were made, neither<br />
regional nor otherwise. Intra-network accountability<br />
mechanisms are very limited, including in El<br />
Salvador and Mozambique.<br />
It seems to be a common feature prevalent at least<br />
to some extent in all three countries, and<br />
particularly in Nepal, that civil society networks<br />
focus on sharing in<strong>for</strong>mation and supporting each<br />
other in matters relating to service delivery rather<br />
than joining <strong>for</strong>ces <strong>for</strong> influencing government-led<br />
processes and contributing to national health plans.<br />
The assumption that networking automatically<br />
means joining <strong>for</strong>ces <strong>for</strong> advocacy and influencing<br />
policy clearly does not hold. It is interesting to note<br />
that ‘trust’ is held up high and appears to be seen<br />
as an adequate replacement <strong>for</strong> more technical<br />
accountability mechanisms.<br />
40 See notes from the Third IHP+ Country <strong>Health</strong> Sector Teams Meeting, 9-10 December 2010 Brussels, Belgium. Available at:<br />
http://www.internationalhealthpartnership.net/en/news/display/3rd_ihp_country_teams_meeting<br />
41 See AfGH 2009
aid effectiveness<br />
19<br />
rivalry and in<strong>for</strong>mation sharing<br />
Between government and civil society<br />
In many countries, particularly in El Salvador and<br />
Mozambique, there is a degree of rivalry between<br />
civil society and governments who see the <strong>for</strong>mer<br />
as potential threats to their work. It may be partly<br />
due to this rivalry in service delivery that some<br />
government representatives are very wary of civil<br />
society engagement overall and consequently<br />
adopt defensive attitudes to their participation in<br />
policy processes as well. Such attitudes sometimes<br />
co-exist with <strong>for</strong>mal guidelines that demand civil<br />
society participation.<br />
Rivalry, as much as complacency and the fact that<br />
civil society are not seen as equal partners, may<br />
also contribute to a lack of in<strong>for</strong>mation provision to<br />
civil society. In El Salvador, Mozambique and Nepal<br />
proactive in<strong>for</strong>mation sharing with civil society by<br />
governments and donors in any systematic way<br />
does not seem to exist. This is un<strong>for</strong>tunate, not<br />
least because access to solid in<strong>for</strong>mation on aid<br />
and health would significantly improve civil society<br />
capacities to contribute to key debates.<br />
civil society capacities<br />
A key reason brought <strong>for</strong>ward by donors and<br />
governments <strong>for</strong> why INGOs and large NGOs are<br />
invited to consultations is that they appear better<br />
organised and seem to have stronger capacities<br />
than many smaller CSOs. Except in El Salvador<br />
perhaps, mostly larger NGOs that are based in<br />
capital cities and have regular internet access and<br />
links to international NGOs are able to conduct<br />
advocacy on a national level. While some<br />
constraints, such as those related to structure and<br />
organisation, may be addressed by CSOs<br />
themselves, other capacity gaps are more easily<br />
addressed with the support of donors, <strong>for</strong> example<br />
in the area of advocacy capacity building.<br />
There are limited incentives <strong>for</strong> CSOs, particularly<br />
smaller ones, to engage in policy processes, not<br />
least because of a history of limited opportunities<br />
<strong>for</strong> participation and influence in most countries. As<br />
a result, such CSOs are unlikely to invest in, or<br />
spend much ef<strong>for</strong>t on, strengthening their advocacy<br />
skills and capacities and their knowledge and<br />
understanding of policy making. However, it is<br />
important to note that civil society participation in<br />
consultation processes will almost automatically<br />
strengthen their knowledge and understanding of<br />
health policy issues and thus strengthen their<br />
capacity.<br />
Nevertheless, if CSOs indeed lack capacity to<br />
adequately confront government specialists in<br />
policy and planning processes this may be taken to<br />
mean that, besides strengthening CSO capacity,<br />
governments and donors need to modify their<br />
processess in order to allow <strong>for</strong> meaningful civil<br />
society participation, even and especially in the<br />
light of limited CSO knowledge and understanding<br />
of policy-making processes. For example, this<br />
could involve donor representatives learning to<br />
speak the language, both culturally and<br />
linguistically, of their host country or community and<br />
thus being able to communicate more effectively.<br />
Using the argument of a ‘weak’ civil society as an<br />
excuse <strong>for</strong> not accommodating meaningful civil<br />
society participation is simply not good enough.<br />
What the interviews also show is that there are<br />
smaller, less ‘obvious’ CSOs that have very valid<br />
and interesting opinions and insights into issues<br />
concerncing aid. While they may not be able to<br />
speak the international aid effectiveness ‘language’<br />
and may not be familiar with agreements such as<br />
Paris Declaration and Accra Agenda <strong>for</strong> <strong>Action</strong>,<br />
they can certainly make valid contributions, ie they<br />
do have the capacity to contribute.<br />
civil society influence on final<br />
outputs<br />
Even where civil society concerns are clearly<br />
articulated and widely discussed in consultations,<br />
they are not necessarily reflected in outputs<br />
derived from them. CSOs in countries like El<br />
Salvador and Nepal feel that despite their<br />
consultation in the development of national health<br />
policies, these policies are nevertheless<br />
government ‘property’, reflecting the power and<br />
influence of donors, but reflecting civil society<br />
concerns only to a very limited extent. It is<br />
important to note that there are different levels of<br />
participation and input: CSOs may be able to make<br />
an impact on very specific and technical<br />
recommendations, but are often sidelined when it<br />
comes to the core aspects of policies and<br />
strategies, which are often strongly influenced by<br />
donors.
20 aid effectiveness<br />
civil society influence on health<br />
outcomes<br />
Whether civil society participation in health policy<br />
making and planning actually influences health<br />
outcomes is difficult to determine, and it is certainly<br />
too early to draw any conclusions from the limited<br />
pool of existing evidence. Nevertheless, it seems<br />
that Nepal, despite lacking key mechanisms <strong>for</strong><br />
systematic representation of civil society, has<br />
managed to take good account of community<br />
concerns and issues affecting marginalised<br />
populations and those living in remote areas.<br />
Likewise, civil society representatives in El<br />
Salvador feel that their views were adequately<br />
reflected in a number of health policy documents<br />
and laws. As far as outcomes are concerned, it<br />
does appear that incorporating CSO<br />
recommendations into health policy and practice<br />
contributes to increasing health access. In Nepal, it<br />
is widely believed that access to healthcare has<br />
improved due to a joint ef<strong>for</strong>t by donors, the<br />
Government and civil society.<br />
recommendations &<br />
lessons learned<br />
overall<br />
■ All development partners must interpret the<br />
principle of ownership in a comprehensive<br />
manner as agreed in the Paris Declaration and<br />
Accra Agenda <strong>for</strong> <strong>Action</strong>. In other words, central<br />
focus must be placed on meaningful<br />
participation of civil society.<br />
■ Meaningful involvement of civil society by<br />
donors and recipient governments means<br />
systematic and <strong>for</strong>malised representation in all<br />
major meetings and consultations, including<br />
time to speak and present. It also means<br />
consulting and involving civil society in early<br />
stages of policy development rather than when<br />
policies are about to be finalised.<br />
■ Donors and governments need to ensure that<br />
adequate follow up is given to CSO<br />
recommendations, <strong>for</strong> example by making civil<br />
society endorsement a <strong>for</strong>mal part of the policy<br />
process.<br />
representation<br />
■ Donors and technical advisers must step up<br />
ef<strong>for</strong>ts to ensure systematic and meaningful<br />
participation of a wider range of civil society,<br />
including CSOs that represent marginalised and<br />
vulnerable groups. This includes promoting the<br />
involvement of a diverse range of CSOs at all<br />
stages of the policy-making and monitoring<br />
process. At the very least, there must be criteria<br />
on national versus international civil society<br />
representation and thematic areas (in order to<br />
prevent all CSO representatives coming from<br />
the HIV and <strong>AID</strong>S sector, <strong>for</strong> example).<br />
■ Donors must reassess their practice of selective<br />
engagement of civil society, ie of engaging<br />
predominantly larger, capital-based<br />
organisations with which they have longstanding<br />
relations. Instead, they must seek to<br />
identify new partners, that may be smaller and<br />
less technology-savvy, but highly committed<br />
and representative of deeper levels of civil<br />
society. Conducting a civil society mapping,<br />
where this does not exist, may be an important<br />
first step in the process.<br />
■ While INGOs are unlikely to be representative<br />
of national or local civil society per se, ways<br />
could be found to harness their strong human<br />
resource and technical capacities to strengthen<br />
national civil society capacity, particularly with<br />
regard to advocacy and their watchdog role, in<br />
any given country. Appropriate provisions could<br />
be incorporated into INGO registration<br />
documents.<br />
■ Donors must actively support partnership<br />
building among all actors. More ef<strong>for</strong>ts are<br />
necessary to improve and strengthen the<br />
relationships between INGOs, local NGOs,<br />
CBOs, local authorities and other parts of civil<br />
society. Thus, alliance building can be fostered<br />
and representation improved.<br />
rivalry<br />
■ Donors should act as brokers between the<br />
Government and civil society, emphasising the<br />
important role of the latter, not only but<br />
particularly in bringing healthcare to<br />
marginalised and remote populations. At the<br />
same time they must also ensure that<br />
governments feel supported.<br />
■ Frequent and open dialogue between all<br />
development stakeholders will gradually break<br />
down barriers and increase mutual interest and<br />
trust. From this point of view, there is a virtuous<br />
circle of civil society participation that builds<br />
trust and thus more involvement, which again<br />
builds trust.
aid effectiveness<br />
21<br />
capacity<br />
■ There is a continuous need <strong>for</strong> targeted funding<br />
to support CSO capacities in advocacy and<br />
policy making. Increased CSO capacity to<br />
monitor policy implementation at community<br />
level and to assess community needs <strong>for</strong><br />
feedback into national planning processes is<br />
also essential. Communities need to be made<br />
aware and become more knowledgeable of<br />
their rights in health, decision making and other<br />
areas.<br />
■ Donors must allocate sufficient aid to<br />
strengthening civil society, making sure that<br />
such opportunities <strong>for</strong> funding are well<br />
disseminated, accessible and straight<strong>for</strong>ward.<br />
CSOs must ensure that their proposals are<br />
systematic and evidence based.<br />
■ Governments and donors must make<br />
in<strong>for</strong>mation on aid available and transparent, as<br />
pledged through the International Aid<br />
Transparency Initiative (IATI). Government<br />
commitments and policies may need to be<br />
translated into the local language, using simple<br />
styles and locally-relevant explanations.<br />
■ Civil society needs to put more ef<strong>for</strong>t into<br />
researching and systematically collecting data<br />
on the ground as a way of preparing evidence<br />
to contribute to policy and planning processes.<br />
Donor support <strong>for</strong> developing CSO capacity in<br />
research and data collection may facilitate this<br />
process. Donors may also support the<br />
development of CSO reports that ‘shadow’<br />
official government reports on development<br />
progress.<br />
outputs and outcomes<br />
■ Civil society and donors must advocate <strong>for</strong> CSO<br />
participation in multi-stakeholder health <strong>for</strong>a to<br />
become a <strong>for</strong>mal requirement in each country.<br />
■ While there is only anecdotal evidence on the<br />
impact of civil society participation on outputs<br />
and health outcomes, it is important that gains<br />
made so far are sustainable. More in-depth<br />
research is needed to refine lessons learned,<br />
gain a deeper understanding of civil society<br />
influence on outputs and outcomes, and identify<br />
precise pathways of influence.<br />
■ Identify mechanisms to ensure CSO<br />
recommendations emerging from joint <strong>for</strong>a are<br />
taken seriously and followed-up, including an<br />
accountability mechanism that enables CSOs to<br />
monitor the process.<br />
■ Solutions must be found <strong>for</strong> engaging the views<br />
of civil society representatives that may not be<br />
able to speak the international aid ‘language’ or<br />
have ‘weak capacities’ in policy as they may still<br />
have valuable opinions and contributions to<br />
improve health and aid effectiveness. Such<br />
solutions will require a certain degree of ef<strong>for</strong>t<br />
and ‘out-of-the-box thinking’ and may, <strong>for</strong><br />
example, involve donors learning to<br />
communicate more effectively with civil society,<br />
both from a cultural as well as from a linguistic<br />
point of view.<br />
Photographs: DSW
22 aid effectiveness<br />
references & further reading<br />
AfGH (2009). <strong>Health</strong> aid effectiveness in Nepal - Paris, Accra, civil society and the poor.<br />
Accessible at http://www.action<strong>for</strong>globalhealth.eu/index.phpid=236<br />
AfGH (2011). Aid Effectiveness <strong>for</strong> <strong>Health</strong>: Making <strong>Health</strong> Aid Work Better.<br />
Accessible at http://www.action<strong>for</strong>globalhealth.eu/index.phpid=126<br />
AfGH and DSW (2010). <strong>Health</strong> spending in Tanzania: the impact of current aid structures and aid<br />
effectiveness. Accessible at http://www.action<strong>for</strong>globalhealth.eu/index.phpid=236<br />
AfGH and DSW (2010). <strong>Health</strong> spending in Uganda: the impact of current aid structures and aid<br />
effectiveness. Accessible at http://www.action<strong>for</strong>globalhealth.eu/index.phpid=236<br />
AfGH and DSW (2011). <strong>Health</strong> Spending in Mozambique: the impact of current aid structures and aid<br />
effectiveness. Accessible at http://www.action<strong>for</strong>globalhealth.eu/index.phpid=236<br />
AfGH and DSW (2011). <strong>Health</strong> Spending in El Salvador: the impact of current aid structures and aid<br />
effectiveness. Accessible at http://www.action<strong>for</strong>globalhealth.eu/index.phpid=236<br />
Bass, A. (2006). A Review to Identify the Role of Civil Society Organizations In Immunization. Prepared <strong>for</strong><br />
the GAVI Secretariat and the GAVI CS Task Team.<br />
DAC Network on Gender Equality (2008). Making the Linkages. Gender Equality, Women’s Empowerment<br />
and the Paris Declaration on Aid Effectiveness: Issues Brief 1. Accessible at<br />
www.oecd.org/dataoecd/52/27/40941110.pdf<br />
IHP+ (2010). Joint Assessment (JANS) of Ghana’s <strong>Health</strong> Sector Medium Term <strong>Health</strong> Development Plan<br />
(HSMTDP) 2010-2013. JANS mission report. Accessible at<br />
http://www.internationalhealthpartnership.net/en/documents/category/joint_ass_1253609049#JANScountry-reports<br />
IHP+ (2010). Third IHP+ Country <strong>Health</strong> Sector Teams Meeting Brussels, 9-10 December 2010; meeting<br />
report. Accessible at<br />
http://www.internationalhealthpartnership.net/en/news/display/3rd_ihp_country_teams_meeting<br />
IHP+ (2011). Joint Assessment of Uganda’s <strong>Health</strong> Sector Strategic & Investment Plan (HSSIP).<br />
Accessible at<br />
http://www.internationalhealthpartnership.net/en/documents/category/joint_ass_1253609049#JANScountry-reports<br />
IHP+ (2011) Report on the Joint Assessment of the Ethiopian National <strong>Health</strong> Sector Strategy. Accessible<br />
at http://www.internationalhealthpartnership.net/en/documents/category/joint_ass_1253609049#JANScountry-reports<br />
IHP+ Results (2011). Strengthening accountability to achieve the health MDGs – Annual Per<strong>for</strong>mance<br />
Report 2010. Accessible at http://ihpresults.net/<br />
JANS Team Vietnam (2011). The Independent Assessment of the Process and the Content<br />
of the Five Year <strong>Health</strong> Plan, 2011-15, in Vietnam. Accessible at<br />
http://www.internationalhealthpartnership.net/en/documents/category/joint_ass_1253609049#JANScountry-reports<br />
London School of Economics (2004). What is Civil Society Accessible at<br />
http://www.lse.ac.uk/collections/CCS/what_is_civil_society.htm
action <strong>for</strong> global health is a network of european<br />
health and development organisations advocating <strong>for</strong><br />
the european union and its member states to play a<br />
stronger role to improve health in development<br />
countries. afgh takes an integrated approach to<br />
health and advocates <strong>for</strong> the fulfilment of the right to<br />
health <strong>for</strong> all. one billion people around the world do<br />
not have access to any kind of healthcare and we<br />
passionately believe that europe can do more to help<br />
change this. europe is the world leader in terms of<br />
overall <strong>for</strong>eign aid spending, but it lags behind in the<br />
proportion that goes to health.<br />
our member organisations are a mix of development<br />
and health organisations, including experts on hiv/aids,<br />
tB or sexual and reproductive health and rights, but<br />
together our work is organised around a broad<br />
approach to health. afgh works to recognise the<br />
interlinkages of global health issues and targets with a<br />
focus on three specific needs: getting more money <strong>for</strong><br />
health, making healthcare accessible to those that<br />
need it most and strengthening health systems to<br />
make them better equipped to cope with challenges<br />
and respond to peoples’ needs.<br />
democratic ownership of development processes<br />
includes parliamentarians, civil society and the private<br />
sector. however, in practice, the principle of ownership is<br />
all too often interpreted as ‘government’ ownership only.<br />
Based on three country case studies in el salvador,<br />
mozambique and nepal and the review of wider literature,<br />
this report presents an overview of recent developments<br />
and the status quo of civil society participation in<br />
development processes.<br />
contact: coordination@action<strong>for</strong>globalhealth.eu<br />
visit our website to learn more about our work and<br />
how to engage in our advocacy and campaign actions.<br />
www.action<strong>for</strong>globalhealth.eu