AID EFFECTIVENESS - Action for Global Health

AID EFFECTIVENESS
progress and the status quo of democratic ownership and
meaningful civil society participation in the health sector

2
ACKNOWLEDGEMENTS
Action for Global Health would like to thank
the people who contributed to this report,
including our consultants Madhusudan
Sharma Subedi (Nepal), Elias Salvador
Ainadine (Mozambique) and Roxana María
Rodríguez (El Salvador) and all the civil
society and government representatives active
in the health sector in Nepal, El Salvador and
Mozambique who agreed to be interviewed.
This report was produced by Action for Global
Health and written by Alice Schmidt,
consultant.
Published in July 2011.
CONTENTS
eXecutive summary: 3
BacKground & introduction: 4
aim & methodology: 5
part 1: cso participation in
improving aid effectiveness: 5
part 2: case study analysis &
comparison Between el
salvador, mozamBique & nepal: 8
el salvador: 8
mozamBique: 10
nepal: 13
other countries: 14
eXamples of Best practice: 16
part 3: cross-country
comparisons & conclusions: 18
recommendations & lessons
learned: 20
references & further reading: 22
Cover Photograph: G.M.B. Akash/Panos/ActionAid
Inside Cover Photograph: DSW
Photograph: DSW

aid effectiveness
3
eXecutive summary
Ownership is the first of the five principles set out in
the Paris Declaration on Aid Effectiveness.
Democratic ownership of development processes
includes parliamentarians, civil society and the
private sector. However, in practice, the principle of
ownership is all too often interpreted as
‘government’ ownership only. Based on three
country case studies and the review of wider
literature, this report presents an overview of recent
developments and the status quo of civil society
participation in development processes.
Civil society participation in development policies is
important for a number of reasons: for example,
civil society can provide a mechanism for checks
and balances, enhance government accountability
and transparency by acting as a watchdog,
represent the voices of poor and marginalised
people.
In the Paris Declaration 2005, and three years later
in the Accra Agenda for Action, governments
committed to “encouraging civil society
participation” in coordinating aid and to “deepen”
their “engagement with CSOs as independent
development actors in their own right whose efforts
complement those of governments and the private
sector”. In other words, governments and donors
agreed to support broad consultative processes in
the development and implementation of national
strategies and acknowledged that civil society
actors have a legitimate role to play in the design
and implementation of country health plans.
As a result, substantial efforts have been made in
inviting civil society to consultations. Overall, civil
society participation has improved, and this is a
point on which governments, donors and civil
society tend to agree. However, despite these
quantitative improvements in civil society
representation, as demonstrated in a number of
recent reviews, there is no conclusive evidence on
progress in regard to qualitative aspects of civil
society representation. For the time being there is
only anecdotal evidence that, nevertheless,
provides some room for cautious optimism.
However, in most countries, there is ample scope
for improved civil society participation and for more
development partners to provide support for more
meaningful participation.
In El Salvador, there are a number of formal
mechanisms for civil society participation. For
example, in 2010 a National Health Forum was
established to allow for consensus-based decisions
in the development of a national health system built
on the right to health, universal coverage, inclusion,
quality and civic engagement. Strong efforts are
being made to adequately represent sub-national
concerns, resulting in CSOs at all levels feeling
well represented. Many CSOs have received
advocacy capacity building and it is felt that civil
society views are adequately reflected in most key
health-related policies. Nevertheless, civil society in
El Salvador is struggling with polarisation along
lines of political affiliation, as well as defensive
attitudes and distrust by the Government towards
CSOs.
In Mozambique, the main health coordination
mechanism does not involve civil society.
Nevertheless, the Government launched a
Development Observatory to establish a
permanent mechanism for hearing the concerns
and aspirations of civil society organisations as
early as 2003. The Observatory has since
expanded to all provinces, thus allowing for subnational
representation. Nevertheless, not all CSOs
feel well represented and there is a view that both
governments and donors tend to invite few, handpicked
organisations to consultations only.
Moreover, even those ‘usual suspects’ do not
always feel that their views are adequately
reflected in outputs and outcomes of consultation
processes. A somewhat antagonistic relationship
between governments and civil society means that
spaces created for civil society participation are not
always used to their full extent.
Nepal has a very diverse civil society that appears
particularly difficult to coordinate. Real efforts at
systematic sub-national or otherwise
representation in national-level consultations does
not seem to exist, neither by civil society itself nor
by the government and development partners.
While Joint Annual Review meetings do bring
together all partners, including civil society, they
provide little practical opportunities for civil society
to share and discuss its views. Despite these
constraints, the concerns of marginalised
populations and those living in remote areas do
seem fairly well reflected in national health policies,
and access to primary healthcare has improved in
recent years.
Obstacles to meaningful participation of civil
society that are common in most countries include
a lack of multi-sectoral mechanisms that formally
and systematically involve civil society, particularly
national and local CSOs; poor efforts at recognising
the diversity of civil society when selecting
participants for consultation; a certain degree of
distrust between government and civil society;

4 aid effectiveness
limited civil society capacities to engage in policy
processes; and a skewed balance of power
between governments, donors and civil society.
Nevertheless, there are a number of best practices
from around the world that can be adapted to and
replicated in other contexts. They range from El
Salvador’s National Health Forum to the
Development Observatory in Mozambique and
Nepal’s data collection system, which provides data
disaggregated by sex, age, caste, ethnicity and
regional identity.
Ensuring the meaningful participation of civil
society in policy and planning is not easy, not least
due to the immense diversity inherent in the
concept of civil society. Nevertheless, where there
is strong political will, practical obstacles can be
overcome and the fruits of accelerated and
improved development can be shared.
BacKground &
introduction
Ownership is the first of the five principles set out in
the Paris Declaration on Aid Effectiveness. It is
important to note that the concept of democratic
ownership of development processes by partner
countries is not limited to partner governments.
Instead, it involves other key players in a
democratic system, particularly ‘domestic
accountability stakeholders’ such as civil society
and parliamentarians. However, in practice, the
principle of ‘country’ ownership is all too often
interpreted narrowly as ‘government’ ownership,
driven by the priorities of the Ministry of Finance.
Broad-based democratic ownership requires
participation by all stakeholders, including civil
society, the media, communities, service providers,
parliament, line ministries and local level
governance structures 1 .
The Task Team on Health as a Tracer Sector is an
informal international health forum which includes
specialists in aid effectiveness and health from
multilateral institutions, bilateral development
agencies, developing countries and NGOs. Its
mandate is to provide the Working Party on Aid
Effectiveness with concrete illustrations of progress
and remaining bottlenecks in the implementation of
the Paris Declaration and Accra Agenda for Action
in the health sector 2 . Its findings on progress in aid
effectiveness, including on democratic ownership,
will feed into discussions at the Fourth High-Level
Forum on Aid Effectiveness to be held in Busan,
South Korea, from 29 November to 1 December
2011. A final report will be released, focusing on
progress in implementing the Paris Declaration
principles and particularly highlighting country
situations 3 .
Photograph: DSW
1 See OECD/DAC (2008)
2 See OECD website http://www.oecd.org/document/55/0,3746,en_2649_3236398_42070263_1_1_1_1,00.html
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
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
health sector (OECD website).

aid effectiveness
5
aim & methodology
The aim of this report is to contribute to the debate
in the lead-up to the Fourth High-Level Forum on
Aid Effectiveness; to provide lessons learned and
models for best practice, particularly in the health
sector; and thus to influence donor and recipient
governments, as well as civil society itself, to
continue focusing on making democratic ownership
of aid effectiveness a reality.
This report was prepared following the review of a
number of reports on health aid effectiveness,
particularly those published by Action for Global
Health (AfGH) and the German Foundation for
World Population (DSW) 4 . Importantly, it is based
on 14 interviews in El Salvador, Mozambique and
Nepal, the findings of which complemented
AfGH/DSW country reports for El Salvador and
Mozambique, and an AfGH report – as well as the
author’s personal experience – on aid effectiveness
in Nepal respectively. It also draws on the most
recently published IHP+ Results study 5 as well as
the Join Assessment National Strategy (JANS)
reports from Ethiopia, Ghana, Uganda and Vietnam
and a few other websites and documents .
After providing an overview of the concept and
benefits of civil society participation, the report
presents the principle of country ownership as
stipulated in the Paris Declaration and refined in
the Accra Agenda for Action. In a second part, El
Salvador, Mozambique and Nepal are presented as
case studies and civil society participation in these
countries is analysed in light of achievements,
challenges and lessons learned. This section also
provides an overview of best practice examples
from El Salvador, Mozambique, Nepal and a few
other countries. A conclusive section compares the
three case studies and draws parallels and
conclusions of significance to developing countries
more generally. Recommendations for the
improvement of civil society participation and
democratic ownership are made at the end.
part 1: cso
participation in
improving aid
effectiveness
definition of civil society
Civil society has been defined in various ways,
reflecting the real diversity of civil society
organisations (CSOs) and also hinting at the
difficulties in providing a comprehensive yet
specific and useful definition.
Some key questions and areas of debate make
defining the term civil society a challenge and have
practical implications on aid effectiveness. For
example, donors and recipient governments are
often reluctant to recognise the role that civil
society actors, including community-based
organisations (CBOs), can play in national policy
making. At the same time, many donors and
recipient governments have begun to recognise
that civil society actors have a legitimate role to
play in the design and implementation of country
health plans and in holding all partners accountable
for delivering results, thus contributing to improved
health outcomes. Another key issue is the lack of
clarity about who represents whom within the
development community. The main challenge in
this regard is how to effectively widen and enhance
engagement of civil society actors at the country
level so as to ensure their meaningful contribution
to the development of country health plans.
The definition of civil society provided by the
London School of Economics’ Centre for Civil
Society Studies illustrates the many complexities of
the concept and highlights the gaps between
aspirations and reality:
“Civil society refers to the arena of uncoerced
collective action around shared interests, purposes
and values. In theory, its institutional forms are
distinct from those of the state, family and market,
though in practice, the boundaries between state,
civil society, family and market are often complex,
blurred and negotiated. Civil society commonly
embraces a diversity of spaces, actors and
institutional forms, varying in their degree of
formality, autonomy and power […]”.
4 Reports are available at www.actionforglobalhealth.eu and www.dsw-brussels.org
5 See website http://www.ihpresult.net

6 aid effectiveness
A more concise and practical definition is provided
by a recent AfGH report, which defines civil society
as “the actors that form an interface between
citizens and their government, including registered
charities, community groups, trade unions, and
faith-based organisations” 6 . This report focuses on
civil society organisations of all sizes and shapes in
the global ‘South’ and uses the AfGH definition of
civil society.
why is civil society participation
important
There are a number of reasons why civil society
participation in development processes is
important. Ensu ring a voice for those that
development processes are supposed to benefit, ie
the clients of development, is an end in itself.
Furthermore, involving civil society can improve aid
effectiveness in a number of ways:
■ The perspectives of communities and
vulnerable groups are brought to the table first
hand, rather than through an extensive range of
intermediaries.
■ CSOs have access to the most vulnerable,
marginalised and difficult-to-reach populations
and are thus able to represent interests that are
all too easily ignored otherwise.
■ Civil society groups can contribute to enhancing
government accountability and transparency by
acting as a watchdog in accountability
mechanisms.
■ Civil society can hold donors to account for the
effective utilisation of development aid.
■ Civil society can bring recipient governments,
donors and communities together, thus
supporting open discussion and greater political
engagement.
■ The principle of democracy requires a system
that allows for checks and balances. These can
be provided by a variety of actors, including
parliaments, civil society, the media, and others.
■ CSOs are important service providers in the
health sector and thus ‘implementers’ of aid,
particularly in marginalised and remote areas.
■ CSOs can build “informed public opinion on
health and shift social attitudes” 8 .
■ CSOs contribute to raising and increasing
awareness and knowledge about citizens’ rights
and other human rights.
Civil society has a long history of engagement in
the health sector, particularly where government
action was lacking. The 1978 Alma-Ata Declaration
was a landmark for recognising people’s
participation in health systems as central to primary
healthcare and for acknowledging the role that
organised social action plays in improving health
outcomes. In many developing countries today, a
significant proportion of healthcare is delivered by
civil society, including non-governmental
organisations (NGOs) and community-based
organisations (CBOs). For example, in Cambodia
30 to 40% of routine immunisation is delivered by
CSOs. The figure rises to 40% for Ghana, Uganda
and Tanzania and as high as 45 to 65% in Northern
Kenya 9 .
■ National health strategies and plans benefit
from the beneficiaries’ perspective and thus
become more appropriate, realistic and
effective.
■ Community participation in programme design
and decision making may play a significant role
in meeting the Millenium Development Goals
(MDGs) 7 .
Photograph: DSW
6 AfGH 2011
7 See for example AfGH 2011 citing S. Commins, Community participation in Service Delivery and Accountability, 2007. See also WHO, Strategic Alliances:
The role of civil society in health, 2001.
8 AfGH 2011
9 Bass 2006

aid effectiveness
7
what was agreed in paris and accra
Ownership is the first of five principles set out in the
2005 Paris Declaration on Aid Effectiveness that
was signed by almost all OECD/DAC donors and
over 60 governments from developing countries 10 .
Its text is outlined in the box below:
ownership: partner countries
eXercise effective leadership over
their development policies and
strategies and coordinate
development actions.
Partner countries commit to:
■ exercise leadership in developing and
implementing their national development
strategies through broad consultative
processes
■ translate these national development
strategies into prioritised results-oriented
operational programmes as expressed in
medium-term expenditure frameworks and
annual budgets
■ take the lead in co-ordinating aid at all levels
in conjunction with other development
resources in dialogue with donors and
encouraging the participation of civil society
and the private sector.
Donors commit to:
■ respect partner country leadership and help
strengthen their capacity to exercise it.
The Paris Declaration very explicitly demanded
“broad consultative processes” in the formulation of
national development strategies and called on
governments to not only enter into a dialogue with
donors, but to encourage the participation of civil
society as well.
In the 2008 Accra Agenda for Action to accelerate
and deepen implementation of the Paris
Declaration, the following statement was included
to demonstrate the importance and elaborate on
the principle of ownership, widening it even more
explicitly towards a concept of broad-based
democratic ownership that emphasises the
participation of parliamentarians, civil society and
other actors:
strengthening country ownership
Developing countries determine and implement
their development policies to achieve their own
economic, social and environmental goals. We
agreed in the Paris Declaration that this would
be our first priority. Today, we are taking
additional steps to turn this resolution into a
reality.
we will Broaden country-level
policy dialogue on development
We will engage in open and inclusive dialogue
on development policies. We acknowledge the
critical role and responsibility of parliaments in
ensuring country ownership of development
processes. To further this objective we will take
the following actions:
■ Developing country governments will work
more closely with parliaments and local
authorities in preparing, implementing and
monitoring national development policies
and plans. They will also engage with civil
society organisations (CSOs).
■ Donors will support efforts to increase the
capacity of all development actors –
parliaments, central and local governments,
CSOs, research institutes, media and the
private sector – to take an active role in
dialogue on development policy and on the
role of aid in contributing to countries’
development objectives.
■ Developing countries and donors will ensure
that their respective development policies
and programmes are designed and
implemented in ways consistent with their
agreed international commitments on
gender equality, human rights, disability and
environmental sustainability.
we will deepen our engagement with
civil society organisations
We will deepen our engagement with CSOs as
independent development actors in their own
right whose efforts complement those of
governments and the private sector. We share
an interest in ensuring that CSO contributions
to development reach their full potential. To this
end:
■ We invite CSOs to reflect on how they can
apply the Paris principles of aid
effectiveness from a CSO perspective.
10 For list of signatories as well as full text of Paris Declaration and Accra Agenda for Action see OECD website.

8 aid effectiveness
■ We welcome the CSOs’ proposal to engage
with them in a CSO-led multi-stakeholder
process to promote CSO development
effectiveness. As part of that process, we
will seek to i) improve coordination of CSO
efforts with government programmes, ii)
enhance CSO accountability for results, and
iii) improve information on CSO activities.
■ We will work with CSOs to provide an
enabling environment that maximises their
contributions to development.
In other words, a significant step towards further
emphasising the importance of civil society
engagement in aid and policy processes was taken
during the Third High-Level Forum in Accra. The
acknowledgment that civil society actors have a
legitimate role to play in the design and
implementation of country health plans and in
holding all partners accountable for delivering
results and achieving improved health outcomes
had been necessary. Donors pledged support
through strengthening the capacity of developing
countries to exercise leadership and for CSOs to
play an active role as “independent development
actors in their own right”.
recent developments
The European Commission is in the process of
developing a Communication on meaningful
engagement of civil society in decision-making
processes and drafting new guidelines on policy
dialogue in the health sector, including a chapter on
inclusive leadership. The aim of these Guidelines
on Policy Dialogue on Global Health is to provide
officials and representatives of the EU with the
information and knowledge they need to establish
regional, national and international dialogue and
political negotiations, which respects and promotes
“values” agreed by the EU and Member States on
global health 11 . However, the process has suffered
from significant gaps in transparency so far and
CSOs have not been informed on how to
participate.
part 2: case study
analysis &
comparison Between
el salvador,
mozamBique & nepal
This section introduces and analyses civil society
participation in health policy processes in El
Salvador, Mozambique and Nepal. After providing
an overview of the health policy environment in
each country, achievements, challenges and
lessons learned are summarised.
el salvador 12
Classified as a middle-income country, El Salvador
has seen aid flows decrease year on year since its
return to democracy two decades ago. Overseas
Development Assistance is now approximately
1.7% of GDP and gradually declining. In this
context, the Government recognises the
importance of increasing aid effectiveness in order
to make the best use of scarce resources. El
Salvador only became a signatory of the Paris
Declaration on Aid Effectiveness in 2009, shortly
before a historic change in government, which
ended the 17-year rule of the Nationalist
Republican Alliance.
The country’s new five-year development plan
2010-2014 was launched in June 2010. Through
this plan, the Government established 10 priority
areas, including poverty reduction and the
promotion of social participation in policy-making
processes. It also establishes a 10-priority vision
for 2024. Until recently, El Salvador’s health sector
had been characterised by severe fragmentation:
instead of a single strategic framework there were
a range of health programmes with little or no
coherence between them. The Ministry of Health’s
organisational structure also reflected this
fragmentation.
Photograph: DSW
11 AfGH 2011
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
9
On paper, the new government has committed to
establishing strong mechanisms for non-state actor
participation. A National Policy for Social
Participation in the Health Sector was elaborated in
2009. However, the policy has not yet come into
force. Nevertheless, a number of participatory
mechanisms were created or strengthened over
the last few years. For example, an intersectoral
committee (CISALUD), made up of government
representatives, civil society and other key
stakeholders, was established as a consultative
entity for policy-making processes.
Among other areas relevant to citizen participation
in health, the Government’s health policy for 2009-
2014 includes the creation of a National Health
Forum (FNS) for the purpose of making
consensus-based decisions in the development of
a national health system based on the right to
health, universal coverage, inclusion, quality and
civic engagement. The Forum was established in
May 2010 when 3,000 participants from around the
country came together in the capital to discuss the
topic “Building Social Participation in Health” 13 . By
acting as an open platform for all non-state actors
working on health, the Forum seeks to overcome
the high degree of civil society fragmentation and
polarisation around party affiliation. The Forum’s
structure is based on a national Organising
Committee and a permanent sub-national structure
to facilitate its activities. A Ministry of Health (MoH)
representative interviewed by DSW for its report on
aid effectiveness in El Salvador stated that they
would like to see the consultation of this entity
become a mandatory precondition for establishing
new policies in the health sector, thus ensuring that
non-state actors can effectively carry out their
policy watchdog role. However, clear terms of
reference, membership adherence rules, as well as
working procedures and consultation rules are yet
to be established.
achievements
■ A document entitled "Commitments for a
National Agenda on Aid Effectiveness" contains
a series of agreements for the implementation
of the principles of the Paris Declaration and
the Agenda for Accra Action in El Salvador. This
document was developed following several
days of consultation with different actors,
including government institutions, civil society,
international NGOs and development partners.
■ Civil society participated in a broad consultative
process in the development of the national
health policy. It is felt that the final document
“Building Hope” adequately reflects the
positions of civil society. CSO positions were
also reflected in the national drug policy, the
draft law on medicines and the plan for health
reform.
■ The National Health Forum has a solid structure
for sub-national representation, with municipal
Forum committees in each of the 262
municipalities. Organisations participating in the
national Forum prepare well, including through
consultations of their constituencies. As a
result, participating organisations feel well
represented and believe they are able to make
a difference.
■ Good relationships between CSOs and local
authorities result in a number of successful joint
initiatives, such as the Joint Initiative for the
Elaboration of Municipal Policies for the Rights
of Girls, Children, Adolescents and Young
Adults; and the Municipal Regulation for
Breastfeeding.
■ Many CSOs participate in some form of donorfunded
advocacy or leadership training related
to their area of expertise, thus strengthening
their ability to participate in multi-stakeholder
processes. In general, these trainings receive
positive evaluations.
■ The MoH recently established a mechanism on
its website, where citizens who feel that their
right to health has been violated can post their
complaints 14 . The effectiveness of this
mechanism remains to be seen.
challenges
■ Civil society is fragmented and polarised along
lines of political affiliation. While the National
Health Forum can absorb some of the resulting
friction, this is an issue that needs to be actively
and continuously considered by government,
donors and civil society itself.
■ Consultative processes, both those led by the
Government and those led by donors, generally
tend to involve the ‘usual suspects’ rather than
a broader range of civil society. For example,
the EU Delegation claims that it regularly
consults civil society regarding country
strategies and thematic projects, but civil
society representatives deny having been
involved. This indicates a lack of diversity in
actors consulted 15 .
13 See www.phmovement.org/en/node/2917 for more information.
14 See www.salud.gob.sv
15 See AfGH/DSW report on El Salvador

10 aid effectiveness
■ MoH staff members are widely seen as being
opposed to civil society participation. Many
CSOs believe that government officials see civil
society as a threat to their status and, as a
result, “do not have the slightest interest” in
working with civil society 16 . Rivalry between the
MoH and CSOs in the area of service delivery
is seen by some as a consequence of
conditionality imposed by the World Bank
wanting to push for a more prominent role for
CSOs.
■ A lack of recognition of the added value that
CSOs can bring to policy-making processes is
another key challenge. Moreover, there is little
confidence in public institutions, which creates
distrust and lack of interest in active
participation on behalf of civil society.
■ Both donors and the Government treat
International NGOs (INGOs), local NGOs and
CBOs very differently. This has many practical
implications, including on resource allocation,
information provision and involvement in
consultation processes. CBOs still tend to be
excluded from many of these processes and
are not seen as equal partners.
■ None of the interviewed people feel that civil
society has access to information regarding aid.
A lack of transparency about government
consultation processes and uncertainty about
possibilities for civil society to get involved in
budgetary scrutiny of public expenditures may
not only compromise the ability of civil society
to engage in any meaningful way but also
contribute to distrust vis-à-vis the
Government 17 .
lessons learned and
recommendations
■ Unifying civil society efforts and working
towards greater motivation and involvement of
community organisations across the country is
key, and it is possible as shown by the success
of the National Health Forum. Nevertheless,
more efforts need to be made to improve and
strengthen the relationship between INGOs,
local NGOs, CBOs, local authorities and
parliamentarians to improve their work as
alliances. Donors should therefore actively seek
to support partnership building among civil
society.
■ As proposed by a MoH representative,
endorsement by the National Health Forum of
new policies and plans should be made an
integral part of the policy process and a
mandatory pre-condition for finalisation of any
health-related policy and plan.
■ Rather than waiting for donors to offer support
for certain activities, such as advocacy and
policy-related capacity building, CSOs must be
proactive in encouraging donors to put
advocacy capacity building on their agenda.
■ The relationship between government and NGO
healthcare providers should be pushed towards
one characterised by collaboration and
complementarity, rather than competition and
rivalry. Donors may facilitate this process by
emphasising the importance of CSOs as
service providers, particularly in bringing
healthcare to remote areas and marginalised
populations, in their regular policy dialogue with
government.
mozambique 18
Mozambique’s Five-Year Development Plan 2010-
2014 launched in early 2010 mentions improving
access to basic social services including health,
particularly for rural populations, as a priority.
Mozambique’s health policy framework is
articulated in several documents, including the
Health Sector Strategic Plan 2007-2012 (PESS).
Stated cornerstones of the policy are primary
healthcare, equity and better quality of care. The
Government’s Plan mentions strengthening of civil
society participation as a key priority for the coming
years. Civil society involvement has seen some
improvement in Mozambique over the last
decades. To a certain extent, this is due to
demands by donors who encouraged the
Government to, in turn, encourage civil society
participation in planning processes.
The 2010 share of external funding within the
national health budget is around 44%, down from
73% in 2008 19 . In other words, aid is a major
contributor to the health sector, particularly in the
areas of infrastructure, human resources and drug
supply. Interviewees feel that the quality of and
access to primary healthcare has improved as a
result of donor support.
Multi-stakeholder Development Observatories at
both national and provincial levels represent civil
society's views on government policy and action.
The national-level Observatory is a multi-sectoral
body composed of representatives of the
16 Interview with Margarita Posada, Coordinator of the National Health Forum and also representing the Citizens’ Alliance Against Privatisation of Health.
17 It should be mentioned that poor access to information is partly due to information systems being weak, thus making access to solid information difficult for
all actors involved.
18 This section is based on interviews conducted with civil society representatives in Mozambique and draws heavily from the AfGH/DSW report on aid
effectiveness in Mozambique.
19 The main reason for this decrease is the fact that funds provided by the Global Fund were recently taken off budget after having been on budget for many
years.

aid effectiveness
11
Government, the donor community and civil
society. Civil society is represented through a group
called the G20, which includes churches, labour
unions, national and international NGOs, the
private sector and academics. Recommendations
emerging from the Development Observatory are
part of the annual aid review. Launched in 2003 as
a government initiative to establish a permanent
mechanism for hearing the concerns and
aspirations of CSOs, the then-called Poverty
Observatory gradually expanded to the provinces,
and in 2008 for the first time meetings were held in
all provincial capitals 20 . Overall, the Observatory
story is one of success:
“The participation of CSOs in the consultations is
positive and increasingly more active and better
informed. The interaction between government and
CSOs is good and as a number of CSOs are
becoming more involved in monitoring policy
implementation at different levels, their contribution
is more and more based on evidence.” 21
However, there is no health coordination
mechanism that systematically, ie formally and
regularly, involves civil society. Nevertheless, two of
the most prominent NGO platforms in
Mozambique, the Mozambican Network of AIDS
Services Organisation (MONASO) and NAIMA
(AIDS Impact Mitigation Association) have been
able to regularly participate in Health Sector Wide
Approach (SWAp) processes, such as the SWAp
Forum, various working groups, and the
elaboration of the Health Strategic Plan. However,
these groups claim that their participation has not
been sufficiently meaningful and follow-up to their
recommendations has been lacking.
achievements
■ The Development Observatories process allows
for systematic engagement of civil society and
has led to civil society views and concerns with
health policies being reflected.
■ Since its expansion to regional capitals in 2008,
the Development Observatory mechanism
allows for adequate regional participation in
consultative and decision-making processes.
■ While there is certainly room for improvement,
health policies today tend to be more inclusive
of stakeholder views and gradually take into
account community needs. This is also partly
due to improved capacity of CSOs to monitor
policy implementation at community level and
feed community needs back into the planning
process.
■ Individual networks and organisations make
serious efforts at representation: MONASO, for
example, has representatives in all provinces
and in all districts where its members work.
District-level concerns are represented in
regular province-level meetings, and elected
representatives from the provinces represent
members at the national level. Representatives
at regional and national level have three- and
five-year mandates respectively. The provincial
and national General Assembly are seen as
accountability mechanisms for members to
recur to as necessary.
■ Some donors, such as the European
Commission, have agreements with the
Government that underpin a shared
responsibility for CSO involvement: The
Cotonou agreement, upon which the EU’s
Memorandum of Understanding (MoU) with
Mozambique is based, specifically recognises
local authorities, parliaments and non-state
actors as partners in development.
■ The Civil Society Support Mechanism (CSSM),
a five-year programme initiated by the UK’s
Department for International Development
(DFID) and Irish Aid, aims to improve
governance and accountability for ordinary
Mozambican citizens. This is undertaken by
strengthening and diversifying the engagement
of Mozambican CSOs through governance
monitoring and advocacy. The CSSM provides
capacity building and grants in the areas of
governance monitoring and advocacy for CSOs
that have innovative, feasible and relevant
project ideas.
■ While many CSOs still find it difficult to access
information concerning aid, most respondents
feel that the IHP+ has created more space for
civil society to engage, especially in passing on
information about the health sector. This
facilitates engagement in national and regional
policy processes.
challenges
■ Civil society is not involved in the Coordination
Committee, said to be Mozambique’s most
influential forum on health and health policy
development. The Coordination Committee
brings together the Ministry of Health and
development partners and meets twice a year.
Decisions made in these meetings feed into the
Ministry’s planning process.
■ CSO networks that get to participate in
consultation processes are not necessarily
representative of civil society. For example, the
two groups that appear to be invited to all key
20 For more information see http://www.undp.org.mz/en/What-we-do/Poverty-and-HIV-AIDS/Press-Releases/Development-Observatories-as-Potential-
Citizenship-Fora
21 Interview with Rosalia Mutisse, Project Officer at HelpAge International.

12 aid effectiveness
national-level consultation processes are
platforms focusing on HIV and AIDS and sexual
and reproductive health, ie on issues that are
favoured by donors and thus receive relatively
large amounts of funding. CSOs working on
other health issues often do not receive as
much funding and cannot establish powerful
advocacy platforms. Consequently, they are not
in the spotlight and not invited for consultation.
■ Some believe that the Government involves
only those CSOs in consultation processes that
are seen to be on its side from a political point
of view. This creates tension among
organisations with different political affiliations
within major CSO platforms.
■ Donors, in their individual consultation
processes, are also guilty of continuously
engaging the same few CSOs – which are
typically large and based in the capital – instead
of seriously aiming for representativeness. This
is partly due to limited donor staff resources,
which makes serious engagement with a
representative range of civil society difficult.
■ Size is another issue. The bigger CSO
networks are, the more difficult it becomes for
their representatives to adequately reflect and
defend civil society’s interests. For example,
MONASO supposedly represents 1,400
members in 102 districts. It admits that finding a
common position, particularly on sensitive
issues such as treatment for sexually
transmitted diseases, remains a challenge.
■ There have been reports of civil society
representatives not making use of their
opportunities for participation. While being
physically present in consultations, some do not
raise their voices at all. To what extent this is
due to dismissive attitudes by government,
which does seem to be an issue, or other
factors, remains unclear.
■ Rivalry and distrust between CSOs and
government are barriers to open dialogue and
negotiation. In many cases, government staff
feel threatened by the active participation of
civil representatives and as a result adopt
defensive attitudes. Such attitudes mean that
spaces created for CSO participation in the
national health sector policies may not be made
full use of and they may be one reason why civil
society participation in joint fora is not always
very active.
■ Many local CSOs lack the capacity to
adequately confront government specialists in
policy, planning and monitoring processes.
However, CSO proposals to donors for capacity
building support get turned down. There are
several examples of CSOs, such as MONASO,
submitting proposals for advocacy-capacity
building to donors and being unsuccessful
because the Government, to whom proposals
get submitted in the process, does not approve,
apparently due to a general distrust towards
CSO advocacy work.
lessons learned and
recommendations
■ In order to improve sub-national representation
and strengthen the voice of communities, a
number of measures can be taken: giving
national CSOs space in meetings, organising
internal consultations before attending key
meetings with donors and government, and
organising regular internal meetings at all
levels. These suggestions by one respondent 22
are ways for ensuring community concerns get
transmitted to national level stakeholders.
■ There is a need for donors and the Government
to actively reach out to a greater diversity of
CSOs in order to make consultation processes
even more representative of Mozambican
society. Moreover, partnership building between
INGOs, CSOs and CBOs needs to be actively
supported. Furthermore, rather than compete
for funding and government attention, INGOs
could focus on capacity building for local CSOs.
■ Rather than seeing each other as rivals in
regard to health service provision, NGOs and
the Government should focus on their
respective added value and thus ensure
complementarity. CSOs’ ability to reach the
most marginalised communities should be
adequately valued by the Government as well
as donors. An NGO service for HIV and AIDS
working in tandem with a local hospital in a rural
district of Mozambique is a positive example of
successful partnership and collaboration.
■ There is a need for an open and transparent
dialogue between CSOs and government
officials, potentially facilitated by donors, to
discuss and address issues around distrust
between CSOs and the Government.
■ Donors must identify ways to ensure those
CSOs who want to apply for advocacy-related
funding do not get discouraged, or rejected,
because of a general ‘fear’ of advocacy by the
Government. In other words, they must review
their grant-making processes.
■ A comprehensive and publicly available
mapping of CSOs would be a first step in
improving the diversity of civil society that
participates in consultations, not least because
it would allow development partners with limited
staff to contact a wider range of more specific
organisations relevant to geographic location
and activity.
22 Interview with Helder White, Programme Director at MONASO (Mozambique Network of AIDS Service Organizations)

aid effectiveness
13
■ Monitoring the real use of the spaces created
for civil society participation would likely provide
important insights, since the degree of CSO
participation depends, to a significant extent, on
encouraging attitudes by individuals, whether
systems for participation exist or not.
nepal 23
In 2007 Nepal introduced a Free Healthcare Policy
that foresees universal free essential health
services at health post and sub-health post levels.
In 2009, a policy to make maternal health services
free at the point of access was also introduced.
Nepal’s Health Sector Programme Implementation
Plan II was developed in 2010 for a period of five
years. Despite clear equity gaps, child and
maternal mortality have improved with increased
access to healthcare:
“The health situation of the country is improving.
For example, maternal and neonatal mortality has
decreased, life expectancy at birth has increased,
immunisation coverage and institutional delivery
have also increased. However, there is disparity
between rural and urban, east and west and
between different caste and ethnic groups.”
Aid effectiveness has been slowly improving since
the early 2000s, when health donors started getting
together regularly in coordination meetings, and 11
donors joined a health SWAp in 2004. Joint Annual
Review meetings take place twice a year, bringing
together donors, government and civil society
under the leadership of the Ministry of Health. A
June review normally focuses on planning and a
November meeting on programmes. After every
review an Aid Memoire is mutually agreed upon to
guide coordinated work for the following six-month
period. Partners are meant to prepare their
organisational plans based on the outcomes of the
reviews. An IHP+ compact was signed by eight
partners in 2009.
With almost 50% of health spending coming from
aid, development assistance is crucial for Nepal.
This ratio also means that it is difficult for the
Government to maintain clear leadership. In
addition, INGOs also channel substantial amounts
of funding to the health sector at community level,
representing yet another, important force. Nepal
has a very diverse civil society, ranging from small,
community-based groups and affected populations,
to large INGOs, that are seen by many mainly as
donors. There are 28,000 registered NGOs, but the
total number of CSOs is estimated at around
40,000; however, relatively speaking, not many
seem to have an explicit focus on health.
achievements
■ Some CSOs do get involved fairly regularly and
systematically in national-level consultations,
such as Joint Annual Reviews. Consulting civil
society in national development processes has
become more frequent.
■ Improvements in access to healthcare and
special attention to the needs of marginalised
groups in policy and budget provisions may be
seen as “a direct result of participation in the
decision-making process at national level” 25 .
One respondent felt that the fact that Nepal’s
Interim Constitution of 2007 pointed to people’s
fundamental right to health was partly due to
CSO influence. Similarly, introduction of free
care is seen as an outcome of “proper
cooperation and coordination among
Government of Nepal, Development Partners
and NGOs in Nepal” 26 .
■ Data disaggregation facilitates the
consideration and monitoring of community
concerns. The Ministry of Health is piloting a
data collection system which uses data
disaggregated by sex, age, caste, ethnicity and
regional identity. This will help monitor which
groups benefit most from abolition of user fees
and other health policies.
■ Respondents feel that the IHP+ makes it easier
for civil society to engage in national and
regional policy processes because of its explicit
focus on meaningful engagement of civil
society.
■ None of the respondents cited a general
distrust of CSOs by the Government as an
issue and one even pointed to the good
relations between government and civil society.
If valid, this can be seen as a great
achievement, not least in light of earlier
assessments that found a certain degree of
polarisation due to political affiliation 27 .
23 This section draws mainly on interviews, as well as an earlier case study by the author (AfGH 2009).
24 Interview with Giridhari Sharma Paudel, Deputy Director General and Chief of Programme of National Family Planning Association.
25 AfGH 2011
26 Interview with Giridhari Sharma Paudel, Deputy Director General and Chief of Programme of National Family Planning Association.
27 See AfGH 2009

14 aid effectiveness
challenges
■ CSO networks do not seem to make great
efforts to adequately represent their members.
Several interviewees stressed that membership
in their respective organisation or network is not
mandatory and based on mutual trust, which
they seem to interpret as there not being a
need for formal efforts at representation.
Networks tend to be seen as vehicles for
information sharing and mutual support on the
programme side rather than for political
influence and representation.
■ There are no systematic efforts at involving an
adequate representation of civil society in the
Joint Annual Reviews. In general, there do not
seem to be any meaningful links between local,
regional and national level civil society in terms
of policy influence. However, many NGOs
working in the districts have an office in the
capital which could represent sub-national
concerns.
■ Some civil society representatives do not feel
that formal mechanisms that guarantee civil
society a place around the policy making table
are adequate: “Government can hire
consultants and civil society members
depending upon its need.” 28
■ CSOs that do get invited to consultative
processes tend to be representatives of large
INGOs or other ‘usual suspects’ who have
personal relationships with donors or
government. One respondent maintained that
“many donor organisations are supporting local
CSOs based on their personal linkages and
trust”. 29
■ Despite the significance of aid in the health
sector, information on aid, or on how to collect
aid-related information, is not systematically
made available. One interviewee mentioned
that “information regarding the aid provided to
the Government by various donor
organisations” is available, while information on
“aid provided to NGOs by different donor
organisations is not”. 30
■ Many CSOs see themselves as ‘supporters’
and ‘assistants’ of government programming
and policy, rather than as right holders in aid
and development. Furthermore, while most
stakeholders seem to agree that the non-state
sector is vital to achieving the MDGs in Nepal,
many view civil society as important only in the
field of service delivery rather than in policy
making.
lessons learned and
recommendations
■ Donors who support civil society organisations
and networks have an important role in
encouraging better representation of subnational
and community priorities and concerns
and thus better reflection of the diversity of civil
society. Donors are in an excellent position to
build and strengthen a culture of representation
due to their close engagement with some key
NGOs and CSOs and because of the financial
support they are able to provide.
■ All development stakeholders have a
responsibility to improve the confidence of
CSOs towards a view that sees civil society as
an equal partner to donors and the
Government. While this view may be
reasonably accepted when it comes to
programming, it is decididly underdeveloped in
regard to policy making and planning. Some
CSOs feel that they can influence the national
health plan by having their projects replicated
and funded by the Government. While this is
true to some extent, their ambitions in regard to
policy influence need to be strengthened.
■ CSOs that are not directly involved in the aid
effectiveness agenda at national level may not
have heard about the Paris principles, the Accra
Agenda for Action or the International Health
Partnership. Nevertheless, they may still have
important contributions to make about policy
and aid effectiveness per se, as demonstrated
in the interviews.
other countries
Largely speaking, the findings in El Salvador,
Mozambique and Nepal are corroborated by
research in other countries and contexts. This
section presents selected findings from other
reviews and assessments.
In April 2011, the IHP+ Results performance report
for 2010 was issued 31 . IHP+ Results is mandated to
annually analyse the performance of each IHP+
signatory individually as well as collectively, assess
results at country level, and to report on whether
commitments and expectations of the IHP+ are
being achieved 32 . The 10 developing countries in its
remit are: Burkina Faso, Burundi, Djibouti, DR
Congo, Ethiopia, Mali, Mozambique, Nepal, Niger
and Nigeria. In order to understand to what extent
28 Interview with Bharat Pradhan, Executive Director of Public Health Concern Trust.
29 idem
30 Interview with Shanta Lall Mulmi, Executive Director of Resource Centre for Primary Healthcare.
31 See References section for full details.
32 The performance report reflects the findings for the second annual cycle of monitoring, undertaken in 2010. It builds on the findings of previous reviews and
will inform the third annual performance review in 2011.

aid effectiveness
15
civil society is bringing community perspectives into
health policy processes and serves as watchdog
for accountability, IHP+ Results reviewed:
■ whether civil society has a seat at the health
sector coordination mechanisms in each
country 33
■ whether development partners support civil
society in engaging with these country
mechanisms.
Governments reported that civil society is
represented in the health coordination mechanism
in seven of the ten countries (all except Djibouti,
Mozambique, and Nigeria). Civil society
representation appeared to be increasing and had
reached at least 10% of participants in countries’
coordination mechanisms in Burundi, DR Congo,
Ethiopia, Mali, Nepal and Niger. In Ethiopia and
Mali civil society constituted 25 and 30% of the
membership of the health sector coordination
mechanism respectively. All development partners
reported that they provide support for civil society
participation in health policy processes.
Nevertheless, the report stresses that further work
is needed to tighten the definition of development
partner ‘support’ to civil society.
Overall, civil society representatives reported that
their engagement in processes to develop national
health plans was increasing. Civil society
representatives becoming more engaged in
national health sector planning processes before
they become formally represented in the country’s
health sector coordination mechanism seems to be
a typical pattern. Among a group of CSOs
connected to the IHP+, most representatives
reported that they were already participating in the
development of national health plans and mutual
accountability mechanisms. Some also reported
making a contribution to and, to varying extents,
influencing the outcomes of national Joint Annual
Health Sector Reviews.
These findings are encouraging, but it must be
emphasised that those CSOs already linked up
with the IHP+ are likely not sufficiently
representative of civil society in these countries
overall. In conclusion, despite observing some
improvement, the report notes that “there is scope
in most countries for further government
engagement of their civil society, and for more
development partner support for civil society, to
become more meaningfully involved in broader
health policy processes”.
A report by AfGH 34 identifies the following major
obstacles to meaningful civil society participation:
■ suspicion and distrust towards CSOs by
Ministry of Health staff
■ skewed balance of power: CSO ‘partners’ are
relied upon to deliver services but not seen as
legitimate actors and equal partners in policy
and planning
■ lack of funding for local CSOs’ capacity building
■ restriction of CSO roles and activities: in
Zambia, for example, proposed legislation
would require all CSOs to operate under threeyear
licenses, making strategic planning and
fundraising extremely challenging
■ lack of transparency and serious consultation:
in Uganda, parliamentarians only have one
month to scrutinise the budget; in Mozambique
and Zambia, health reports are not made
available to parliament at all.
Nevertheless, a number of Joint Assessment of
National Strategies (JANS) find that civil society
participation has been increasing and successfully
influenced policy processes in several instances. In
Ghana, for example, the joint assessment of the
Health Sector Medium Term Health Plan 2010-
2013 found that the Government had made a “good
effort” to get inputs from a broad range of
stakeholders, including civil society. Furthermore, a
multi-sectoral Partners’ Forum that is led by the
MoH meets monthly to discuss health-related
issues. Besides senior MoH staff, this Forum
includes development partners, faith-based
organisations and other civil society
representatives 35 .
In Ethiopia, the JANS process provided a first-time
opportunity for CSOs and NGOs to comment on
Ethiopia’s National Health Sector Development
Plan IV in an organised manner. Most civil society
comments on the draft were reportedly included in
the revised version. Moreover, CSOs and NGOs
were given an additional opportunity to comment
when the JANS steering committee, together with
33 The health coordination mechanism is usually a government-led body comprising of domestic and international stakeholders in the health sector; it is not
the Global Fund country coordination mechanism, but there may be overlaps.
34 See AfGH 2011
35 See IHP+ (2010) report on Ghana

16 aid effectiveness
CSO umbrella organisations, arranged a workshop
“to encourage and enable their optimum
participation” 36 . In other words, JANS provided a
mechanism for systematic engagement of CSOs
that had not been involved in health policy making
previously.
While referring to civil society participation at times,
the JANS report on Vietnam provides little
information on the extent and nature of civil society
participation in the development of Vietnam’s fiveyear
health plan 2011-2015. Nevertheless, it clearly
states that civil society participation must be
strengthened further 37 .
eXamples of Best
practice
The following examples, many of which were
introduced earlier, can be considered best practice
worthy of being adapted or replicated in other
contexts. It should be noted, nevertheless, that
these mechanisms may also have weaknesses,
particularly in relation to participation by CSOs and
CBOs based outside major cities.
Best practice of civil society
participation around the world
el salvador
National
Health Forum
(FNS)
ghana
Partners’
Forum
36 See IHP+ (2011) report on Ethiopia
37 See JANS Team 2011
The Forum was designed as
an open platform to unify the
voices of a very diverse and
fragmented civil society and
to strengthen capacity of nonstate
actors working on
health. With FNS, municipal
committees in each of the
262 municipalities and a clear
organisational structure,
regional representation is
possible.
A Partners’ Forum led by the
MoH meets monthly to
discuss health-related issues.
This Forum includes
development partners, faithbased
organisations and
other civil society
representatives besides
senior MoH staff.
mozambique
Development
Observatory
nepal
Data
disaggregation
tanzania
Civil society
support website
Development Observatories
at both national and
provincial levels represent
civil society's views on
government policies and
actions. Launched in 2003 as
a government initiative to
establish a permanent
mechanism for hearing the
concerns and aspirations of
CSOs, the then Poverty
Observatory gradually
expanded to the provinces.
The national-level
Observatory is composed of
representatives of the
Government, the donor
community and civil society.
Civil society is represented
through a group called the
G20, which includes
churches, labour unions,
national and INGOs, the
private sector and
academics.
Recommendations emerging
from the Development
Observatory are part of the
annual aid review.
Data disaggregation
facilitates the consideration
and monitoring of community
concerns. The MoH is piloting
a data collection system
which uses data
disaggregated by sex, age,
caste, ethnicity and regional
identity. This will help monitor
which groups benefit most
from abolition of user fees
and other health policies.
The EU Commission and
Canada, with the contribution
of all major donors in
Tanzania, have established a
civil society support website
that contains and compares
different funding opportunities
for civil society, both for
advocacy and service
delivery, by donor, sector and
region
(www.civilsocietysupport.net).

aid effectiveness
17
uganda
global
Independent
Development
Fund
Inclusive and
participatory
development
of national
health
strategy
Uganda’s Independent
Development Fund was set
up to deliver a range of
support services to Ugandan
CSOs as a means of
strengthening their capacities
to effectively contribute to
human and civil rights, good
governance and poverty
reduction. Supported by the
Danish, Dutch, Irish, Swedish
and UK governments through
their development agencies,
it is open almost exclusively
for proposals from national
CSOs and CBOs; INGOs can
only apply as part of a
consortium (www.idf.co.ug).
A joint assessment revealed
that the Government has
made proactive efforts to
ensure engagement of a
broad range of non-state
health actors in the
development of Uganda’s
Health Sector Strategic and
Investment Plan 2010/11-
2014/15. Sub-national
engagement was also
sought, and consultations
were also held with districts
and with other sectors and
initiatives relevant to health.
Civil society participation was
found to be very vibrant and
active and several
consultations on the Plan
were held and
recommendations submitted.
Global Fund
country
coordinating
mechanism
Civil society
participation
in IHP+
Despite its limitations, the
national coordinating
mechanism of the Global
Fund is considered a best
practice model for civil
society and parliamentary
engagement by many
CSOs 38 . The Community
Systems Strengthening
Framework developed by the
Global Fund in collaboration
with the World Health
Organization (WHO),
UNAIDS and CSOs provides
an important guidance on
how to support civil society
capacity-building activities
and strengthen community
systems.
The IHP+ represents both
Northern and Southern civil
society in its global
management structure. It has
been shown that in countries
where an IHP+ Compact is
signed, civil society
participation in decisionmaking
processes
increases 39 .
Health Policy
Advisory
Committee
The Committee is composed
of representatives from the
MoH and key donors,
meeting on a regular basis in
order to provide policy
guidance to the sector. CSOs
and members of parliament
are invited to each annual
health sector review in order
to contribute to the
discussions on past
performance and future work.
38 See for example AfGH/DSW (2010) report on Tanzania.
39 See notes from the Third IHP+ Country Health Sector Teams Meeting, 9-10 December 2010, Brussels, Belgium. Available at:
http://www.internationalhealthpartnership.net/en/news/display/3rd_ihp_country_teams_meeting

18 aid effectiveness
part 3: cross-country
comparisons &
conclusions
Inviting civil society to consultations on health
policy has become fairly common, and it is fair to
say that overall, both government and donors make
active efforts to encourage and increase civil
society engagement. However, donor and
government partnerships with civil society as
service providers are often confounded with civil
society participation in advocacy. In other words,
while CSOs play a significant and well-recognised
role in service delivery in many countries, they
often are excluded from policy-making processes.
Moreover, without in-depth qualitative research it is
very difficult to determine how meaningful even
active participation of civil society in policy
processes has been. Simply knowing that civil
society ‘participated’ in a certain consultation does
not provide information on:
■ who exactly participated, ie whether one or
more civil society representatives participated,
what part of civil society they represent,
whether they are members of a large INGO or
network, or belong to a small CBO, etc
■ how actively civil society contributed, ie whether
they contributed at all and in what manner
■ whether civil society contributions were taken
seriously by government and donors and
provided space for discussion
■ whether civil society recommendations were
reflected in the final output, such as a policy or
a plan.
In order for civil society participation in national
policy and planning processes to be meaningful, ie
to respond to qualitative criteria as well as
quantitative ones, political will of both donor and
recipient governments is essential. In view of the
immense diversity of civil society, meaningful
participation is not easy to achieve. Therefore,
political will must be strong, serious and
pronounced. In order to address some of the
practical challenges, civil society, recipient
governments and donors can learn from the best
practices provided in this document and pick and
adapt elements that are relevant to their respective
country contexts.
representation
There are obvious challenges in managing and
representing “what is a large and amorphous
constituency” without losing a healthy diversity 40 .
This is true both for regional, sectoral and structural
representation. It must be noted that consulting all
civil society, or even a representative sample, is not
possible due to the enormous diversity, both
organisatonally and sectorally. For example, in
Nepal there are 28,000 registered NGOs and at
least 10,000 CSOs that are unregistered 41 . In a
population of 28 million this means that there is one
registered NGO for every 1,000 people. There have
been criticisms of some NGOs being set up
exclusively as a money-making opportunity for their
founders. Whatever the truth may be, this is not an
excuse for consistently consulting the same few
NGOs based in the capital that receive
considerable international funding and thus speak
an ‘international’ language.
In some countries, such as El Salvador and
Mozambique, extensive consultations within civil
society are organised and there are processes at
sub-national level that aim to approximate regional
representation in national-level meetings. In El
Salvador’s National Health Forum, in particular,
substantial thought is given to appropriate
reflection of the diversity of interests, and
mechanisms are in place that approximate
adequate representation. Furthermore, CSOs at
regional and district level directly interact with local
authorities, thus working through another important
channel of influence. While Nepalese CSOs also
interact with local authorities, none of the CSOs
interviewed indicated that substantial or systematic
efforts at representation were made, neither
regional nor otherwise. Intra-network accountability
mechanisms are very limited, including in El
Salvador and Mozambique.
It seems to be a common feature prevalent at least
to some extent in all three countries, and
particularly in Nepal, that civil society networks
focus on sharing information and supporting each
other in matters relating to service delivery rather
than joining forces for influencing government-led
processes and contributing to national health plans.
The assumption that networking automatically
means joining forces for advocacy and influencing
policy clearly does not hold. It is interesting to note
that ‘trust’ is held up high and appears to be seen
as an adequate replacement for more technical
accountability mechanisms.
40 See notes from the Third IHP+ Country Health Sector Teams Meeting, 9-10 December 2010 Brussels, Belgium. Available at:
http://www.internationalhealthpartnership.net/en/news/display/3rd_ihp_country_teams_meeting
41 See AfGH 2009

aid effectiveness
19
rivalry and information sharing
Between government and civil society
In many countries, particularly in El Salvador and
Mozambique, there is a degree of rivalry between
civil society and governments who see the former
as potential threats to their work. It may be partly
due to this rivalry in service delivery that some
government representatives are very wary of civil
society engagement overall and consequently
adopt defensive attitudes to their participation in
policy processes as well. Such attitudes sometimes
co-exist with formal guidelines that demand civil
society participation.
Rivalry, as much as complacency and the fact that
civil society are not seen as equal partners, may
also contribute to a lack of information provision to
civil society. In El Salvador, Mozambique and Nepal
proactive information sharing with civil society by
governments and donors in any systematic way
does not seem to exist. This is unfortunate, not
least because access to solid information on aid
and health would significantly improve civil society
capacities to contribute to key debates.
civil society capacities
A key reason brought forward by donors and
governments for why INGOs and large NGOs are
invited to consultations is that they appear better
organised and seem to have stronger capacities
than many smaller CSOs. Except in El Salvador
perhaps, mostly larger NGOs that are based in
capital cities and have regular internet access and
links to international NGOs are able to conduct
advocacy on a national level. While some
constraints, such as those related to structure and
organisation, may be addressed by CSOs
themselves, other capacity gaps are more easily
addressed with the support of donors, for example
in the area of advocacy capacity building.
There are limited incentives for CSOs, particularly
smaller ones, to engage in policy processes, not
least because of a history of limited opportunities
for participation and influence in most countries. As
a result, such CSOs are unlikely to invest in, or
spend much effort on, strengthening their advocacy
skills and capacities and their knowledge and
understanding of policy making. However, it is
important to note that civil society participation in
consultation processes will almost automatically
strengthen their knowledge and understanding of
health policy issues and thus strengthen their
capacity.
Nevertheless, if CSOs indeed lack capacity to
adequately confront government specialists in
policy and planning processes this may be taken to
mean that, besides strengthening CSO capacity,
governments and donors need to modify their
processess in order to allow for meaningful civil
society participation, even and especially in the
light of limited CSO knowledge and understanding
of policy-making processes. For example, this
could involve donor representatives learning to
speak the language, both culturally and
linguistically, of their host country or community and
thus being able to communicate more effectively.
Using the argument of a ‘weak’ civil society as an
excuse for not accommodating meaningful civil
society participation is simply not good enough.
What the interviews also show is that there are
smaller, less ‘obvious’ CSOs that have very valid
and interesting opinions and insights into issues
concerncing aid. While they may not be able to
speak the international aid effectiveness ‘language’
and may not be familiar with agreements such as
Paris Declaration and Accra Agenda for Action,
they can certainly make valid contributions, ie they
do have the capacity to contribute.
civil society influence on final
outputs
Even where civil society concerns are clearly
articulated and widely discussed in consultations,
they are not necessarily reflected in outputs
derived from them. CSOs in countries like El
Salvador and Nepal feel that despite their
consultation in the development of national health
policies, these policies are nevertheless
government ‘property’, reflecting the power and
influence of donors, but reflecting civil society
concerns only to a very limited extent. It is
important to note that there are different levels of
participation and input: CSOs may be able to make
an impact on very specific and technical
recommendations, but are often sidelined when it
comes to the core aspects of policies and
strategies, which are often strongly influenced by
donors.

20 aid effectiveness
civil society influence on health
outcomes
Whether civil society participation in health policy
making and planning actually influences health
outcomes is difficult to determine, and it is certainly
too early to draw any conclusions from the limited
pool of existing evidence. Nevertheless, it seems
that Nepal, despite lacking key mechanisms for
systematic representation of civil society, has
managed to take good account of community
concerns and issues affecting marginalised
populations and those living in remote areas.
Likewise, civil society representatives in El
Salvador feel that their views were adequately
reflected in a number of health policy documents
and laws. As far as outcomes are concerned, it
does appear that incorporating CSO
recommendations into health policy and practice
contributes to increasing health access. In Nepal, it
is widely believed that access to healthcare has
improved due to a joint effort by donors, the
Government and civil society.
recommendations &
lessons learned
overall
■ All development partners must interpret the
principle of ownership in a comprehensive
manner as agreed in the Paris Declaration and
Accra Agenda for Action. In other words, central
focus must be placed on meaningful
participation of civil society.
■ Meaningful involvement of civil society by
donors and recipient governments means
systematic and formalised representation in all
major meetings and consultations, including
time to speak and present. It also means
consulting and involving civil society in early
stages of policy development rather than when
policies are about to be finalised.
■ Donors and governments need to ensure that
adequate follow up is given to CSO
recommendations, for example by making civil
society endorsement a formal part of the policy
process.
representation
■ Donors and technical advisers must step up
efforts to ensure systematic and meaningful
participation of a wider range of civil society,
including CSOs that represent marginalised and
vulnerable groups. This includes promoting the
involvement of a diverse range of CSOs at all
stages of the policy-making and monitoring
process. At the very least, there must be criteria
on national versus international civil society
representation and thematic areas (in order to
prevent all CSO representatives coming from
the HIV and AIDS sector, for example).
■ Donors must reassess their practice of selective
engagement of civil society, ie of engaging
predominantly larger, capital-based
organisations with which they have longstanding
relations. Instead, they must seek to
identify new partners, that may be smaller and
less technology-savvy, but highly committed
and representative of deeper levels of civil
society. Conducting a civil society mapping,
where this does not exist, may be an important
first step in the process.
■ While INGOs are unlikely to be representative
of national or local civil society per se, ways
could be found to harness their strong human
resource and technical capacities to strengthen
national civil society capacity, particularly with
regard to advocacy and their watchdog role, in
any given country. Appropriate provisions could
be incorporated into INGO registration
documents.
■ Donors must actively support partnership
building among all actors. More efforts are
necessary to improve and strengthen the
relationships between INGOs, local NGOs,
CBOs, local authorities and other parts of civil
society. Thus, alliance building can be fostered
and representation improved.
rivalry
■ Donors should act as brokers between the
Government and civil society, emphasising the
important role of the latter, not only but
particularly in bringing healthcare to
marginalised and remote populations. At the
same time they must also ensure that
governments feel supported.
■ Frequent and open dialogue between all
development stakeholders will gradually break
down barriers and increase mutual interest and
trust. From this point of view, there is a virtuous
circle of civil society participation that builds
trust and thus more involvement, which again
builds trust.

aid effectiveness
21
capacity
■ There is a continuous need for targeted funding
to support CSO capacities in advocacy and
policy making. Increased CSO capacity to
monitor policy implementation at community
level and to assess community needs for
feedback into national planning processes is
also essential. Communities need to be made
aware and become more knowledgeable of
their rights in health, decision making and other
areas.
■ Donors must allocate sufficient aid to
strengthening civil society, making sure that
such opportunities for funding are well
disseminated, accessible and straightforward.
CSOs must ensure that their proposals are
systematic and evidence based.
■ Governments and donors must make
information on aid available and transparent, as
pledged through the International Aid
Transparency Initiative (IATI). Government
commitments and policies may need to be
translated into the local language, using simple
styles and locally-relevant explanations.
■ Civil society needs to put more effort into
researching and systematically collecting data
on the ground as a way of preparing evidence
to contribute to policy and planning processes.
Donor support for developing CSO capacity in
research and data collection may facilitate this
process. Donors may also support the
development of CSO reports that ‘shadow’
official government reports on development
progress.
outputs and outcomes
■ Civil society and donors must advocate for CSO
participation in multi-stakeholder health fora to
become a formal requirement in each country.
■ While there is only anecdotal evidence on the
impact of civil society participation on outputs
and health outcomes, it is important that gains
made so far are sustainable. More in-depth
research is needed to refine lessons learned,
gain a deeper understanding of civil society
influence on outputs and outcomes, and identify
precise pathways of influence.
■ Identify mechanisms to ensure CSO
recommendations emerging from joint fora are
taken seriously and followed-up, including an
accountability mechanism that enables CSOs to
monitor the process.
■ Solutions must be found for engaging the views
of civil society representatives that may not be
able to speak the international aid ‘language’ or
have ‘weak capacities’ in policy as they may still
have valuable opinions and contributions to
improve health and aid effectiveness. Such
solutions will require a certain degree of effort
and ‘out-of-the-box thinking’ and may, for
example, involve donors learning to
communicate more effectively with civil society,
both from a cultural as well as from a linguistic
point of view.
Photographs: DSW

22 aid effectiveness
references & further reading
AfGH (2009). Health aid effectiveness in Nepal - Paris, Accra, civil society and the poor.
Accessible at http://www.actionforglobalhealth.eu/index.phpid=236
AfGH (2011). Aid Effectiveness for Health: Making Health Aid Work Better.
Accessible at http://www.actionforglobalhealth.eu/index.phpid=126
AfGH and DSW (2010). Health spending in Tanzania: the impact of current aid structures and aid
effectiveness. Accessible at http://www.actionforglobalhealth.eu/index.phpid=236
AfGH and DSW (2010). Health spending in Uganda: the impact of current aid structures and aid
effectiveness. Accessible at http://www.actionforglobalhealth.eu/index.phpid=236
AfGH and DSW (2011). Health Spending in Mozambique: the impact of current aid structures and aid
effectiveness. Accessible at http://www.actionforglobalhealth.eu/index.phpid=236
AfGH and DSW (2011). Health Spending in El Salvador: the impact of current aid structures and aid
effectiveness. Accessible at http://www.actionforglobalhealth.eu/index.phpid=236
Bass, A. (2006). A Review to Identify the Role of Civil Society Organizations In Immunization. Prepared for
the GAVI Secretariat and the GAVI CS Task Team.
DAC Network on Gender Equality (2008). Making the Linkages. Gender Equality, Women’s Empowerment
and the Paris Declaration on Aid Effectiveness: Issues Brief 1. Accessible at
www.oecd.org/dataoecd/52/27/40941110.pdf
IHP+ (2010). Joint Assessment (JANS) of Ghana’s Health Sector Medium Term Health Development Plan
(HSMTDP) 2010-2013. JANS mission report. Accessible at
http://www.internationalhealthpartnership.net/en/documents/category/joint_ass_1253609049#JANScountry-reports
IHP+ (2010). Third IHP+ Country Health Sector Teams Meeting Brussels, 9-10 December 2010; meeting
report. Accessible at
http://www.internationalhealthpartnership.net/en/news/display/3rd_ihp_country_teams_meeting
IHP+ (2011). Joint Assessment of Uganda’s Health Sector Strategic & Investment Plan (HSSIP).
Accessible at
http://www.internationalhealthpartnership.net/en/documents/category/joint_ass_1253609049#JANScountry-reports
IHP+ (2011) Report on the Joint Assessment of the Ethiopian National Health Sector Strategy. Accessible
at http://www.internationalhealthpartnership.net/en/documents/category/joint_ass_1253609049#JANScountry-reports
IHP+ Results (2011). Strengthening accountability to achieve the health MDGs – Annual Performance
Report 2010. Accessible at http://ihpresults.net/
JANS Team Vietnam (2011). The Independent Assessment of the Process and the Content
of the Five Year Health Plan, 2011-15, in Vietnam. Accessible at
http://www.internationalhealthpartnership.net/en/documents/category/joint_ass_1253609049#JANScountry-reports
London School of Economics (2004). What is Civil Society Accessible at
http://www.lse.ac.uk/collections/CCS/what_is_civil_society.htm

action for global health is a network of european
health and development organisations advocating for
the european union and its member states to play a
stronger role to improve health in development
countries. afgh takes an integrated approach to
health and advocates for the fulfilment of the right to
health for all. one billion people around the world do
not have access to any kind of healthcare and we
passionately believe that europe can do more to help
change this. europe is the world leader in terms of
overall foreign aid spending, but it lags behind in the
proportion that goes to health.
our member organisations are a mix of development
and health organisations, including experts on hiv/aids,
tB or sexual and reproductive health and rights, but
together our work is organised around a broad
approach to health. afgh works to recognise the
interlinkages of global health issues and targets with a
focus on three specific needs: getting more money for
health, making healthcare accessible to those that
need it most and strengthening health systems to
make them better equipped to cope with challenges
and respond to peoples’ needs.
democratic ownership of development processes
includes parliamentarians, civil society and the private
sector. however, in practice, the principle of ownership is
all too often interpreted as ‘government’ ownership only.
Based on three country case studies in el salvador,
mozambique and nepal and the review of wider literature,
this report presents an overview of recent developments
and the status quo of civil society participation in
development processes.
contact: coordination@actionforglobalhealth.eu
visit our website to learn more about our work and
how to engage in our advocacy and campaign actions.
www.actionforglobalhealth.eu