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Community Centered Health Systems for improved governance and accountability in Health: An Analysis of the COPASAH Symposium- Denis Bukenya (PHM Uganda)

Community Centered Health Systems for improved governance and accountability in Health: An Analysis of the COPASAH Symposium

Denis Bukenya (People’s Health Movement Uganda/HURIC)

The title to the COPASAH Symposium alone set the pace to this Analysis, “Leaving no one behind: Strengthening Community Centred Health Systems for Achieving Sustainable Development Goals”. This title in my mind alludes to a commitment to serve people and humanity through a more democratic approach that allows them to be involved in their own health challenge solving and development. It is important to note that many marginalized people’s lives in the community are in jeopardy the world over hence the need for community ethos and creation of a conversation between grassroots practitioners, policy advocates, research and academia, policy makers and the implementer. The symposium encased a motley of approaches from the grassroots, practitioners, researchers and academia, policy makers and implementers from all over world, uniquely modeled to gainfully engage members of community and their leaders to improve governance and encourage community accountability.

While COPASAH has been run since 2011, this was my first time to attend the event. The practitioners use social accountability approaches to strengthen the linkage between communities and the health systems to provide quality and accountable care. The symposium revolved around five themes emanating from a specific theme anchor of Leaving No One Behind: Strengthening Community Centered Health Systems for Achieving Sustainable Development Goals. This year, the symposium was organized at the India Habitat Center, New Delhi-India. Approximately 500 people were in attendance from diverse political, social and cultural contexts including COPASAH members from Latin America, Southern Central Europe, Sub Saharan Africa, Eastern and Southern Asia along with researchers, donors and policy makers in the field of public health governance.

The five major areas considered included: Community Action; Indigenous and Marginalized Peoples; Sexual & Reproductive Health and Rights; the Private Sector in Health and Health Workers. Alongside plenaries and parallel sessions, the Symposium comprised workshops, dramas, cultural events and film screenings, and a poster exhibition. Dedicated sessions for regional consultations allowed time for in-depth consideration of the draft COPASAH Charter and Call to Action, as well as other geographic-based discussions. Most importantly, the vast majority of participants hailed from the Global South. I should say that the Arab region, North Africa, and the Pakistan perspectives were greatly missed.

Although in this case the outcomes were fairly benign, the structure and content of the Symposium and the discussions were fascinating. Owing from my point of view, combined with my experiences at such Global Health fora, below I outline what I have learned about citizenship, governance and accountability in health considering strengthened community centered health systems.

The need to continuously empower Civil Society as a feat for citizens’ voices

The narrative showed that Development cooperation has been highly characterized and the Civil Society Oorganizations (CSO) are being steered towards certain actions over others depending on the funding curve of the donor. Multinational corporations have tuned development corporation into a weapon to disguise profit in the health sector. So many examples were sited, notably was the issue of medical tourism in India where the doctors will treat all cost regardless of the survival rate of the patients.

Evidence interrogated at the symposium showed that due to these deliberate efforts through aid and other Civil Society Organization partnerships, the focus has turned to treatment rather than prevention. Simply because the multinational corporations will then line their pockets for trade and profits. Truly so, development corporation focusing on prevention is steadily dwindling. The broader challenges that I hailed the symposium for exposing in the SDG era were the numerous partnerships that have widely opened the floodgates to the private sector which stands for profits at the expense of ill health.

Clearly the practitioners in a bid to fast track strategy shared how they have countered this challenge in their various jurisdictions. The most memorable approach was to form coalitions and muster collective responsibility embanked with numerous community voices to their leaders in demand for sanity. I also got to learn that visual art is a tool of advocacy that appeals most to the youth and the young.

 The conflation between treatment and prevention is problematic

Within the Global Health agenda, Universal Health Coverage (UHC) issues are being framed in terms of treatment solutions. Solutions that, for example, propose public private partnerships to accelerate access to pharmaceutical products. Jane Nalunga, the Country Director of SEATINI/Uganda described how reallocation of power in decision-making, funding and provision of health services from the state to private sector actors and donors continues the exclusion of communities from information, decisions and feedback regarding their health care. More evidently so, the UN General Assembly high level meeting, 2019, prevention was hardly mentioned but the justification of the need for private partners. Chris Owalla the Executive Director of Community Initiative Action Group Kenya (CIAGK) based in Kisumu, Kenya at one of the sessions questioned the narrative as to whether we are still in focus of the debate to help a people at the grass-root when we keep discussing how to make a UHC funded by private public partnerships. We ought to have taken more time questioning this assumption. However, the discussions soon turned to circular debates over engaging with “health harming” industries such as food and alcohol. This illustrates the situation at COPASAH, where civil society (the People’s Health Movement and a few other NGOs) felt they had to interrupt the plenary to have their voices heard, to help support the brilliant panelists points. My analysis is that civil society are in “an abusive relationship with industry”, Global Health is an uncomfortable third wheel in this long-term relationship between Public Health and trans-national corporations.

The commercial determinants of health are at the top of everyone’s intellectual agenda – but action is not being funded

The most energized and well attended session at COPASAH was the excellent People’s Health Movement-led session on the commercial determinants of health and political economy of health. Although the atmosphere was one of activism the audience contained a range of delegates, including those from the global governance of health list like the WHO. The discussions did not progress and likely only served to re-enforce pre-existing assumptions on both sides. While the importance of tackling the commercial determinants of health at the community level is widely agreed, as mentioned above this is not reflected in funding flows. This highlights the challenges for Global Health actors to implement research and projects that may displease their donors; donors who are beholden to private capital flows that may well be invested in the products that public health evidence now shows to be so harmful. In other words the political economy of Global Health in action. To my disappointment, the debate turned political and I really felt like my fellow community activists were denied the opportunity to process the information to make it actionable. It is at that point that I made the suggestion as a way forward that there is a need for PHM to continue simplifying the messages in their policy briefs and share the information widely on the pros and cons of the financial determinants of health and the political economy of health making it more actionable for grass-root consumption.

 Global Health and the Neoliberal Global Political Economy

The governance and accountability in health is dominated by the ideology of neo-liberalism, which places the individual and free-market at the centre. It is important to view global health as part of a system that has increased inequality and inequity and strangely so it seems a fantasy to expect the opposite. The appropriation by many actors in the global health economy has distracted the understanding of the political economy within Global Health. There is a fear that by holding a symposium on governance and accountability in health, and self-congratulate ourselves on seeking to address the issues of governance and accountability hence the inequality, a box is ticked and it is business as usual. We need more governance and accountability analysis of Health systems and the community institutions. But who will fund it? Who will publish it?

The aim of COPASAH was to: “identify major bottlenecks, root causes and propose solutions from the grass-roots to the national and global level to accelerate implementation of proper health systems governance and accountability in health. Whilst the foreseeable objectives were fulfilled, it begs the question as why solutions to the root causes were not forthcoming. Further questions coming to mind were: should the symposium have further considered an elite UN dominated Global Health symposium to better interrogate the governance and accountability in health? I am not so sure.

Moving Forward

To conclude, here is my observation and personal analysis to those who attended the symposium and would love to see change in the current status quo in Global Health.

1) The demand for access to information at the grass-roots needs to be demanded even at Global level. We need to interrupt proceeding to refrain from using words like business as usual. We need to demand that Aid through our global leaders is relaxed to serve at the grass-roots. The negotiations should be made public notice for communities to have meaning-full participation: It is important that communities demand collectively for protection from pandemics by the global health leaders, to fight infectious diseases, to find the cure for cancer if possible, an support nations as they work out a formula towards a Universal Health Coverage dully financed by national taxes and also be open to sharing the data generated.

2) There is an ardent need to continuously critique and work with the UN systems at all levels so that its engagement with the member states can periodically get reviewed on their safe-guarding norms and aspiring to global goals with evidence from the communities.

3) In the meantime, let’s use the data Global Health generates more smartly – to show what is not happening as well as what is. And to use more political economy analysis to help show why.

4) Let’s dump down the messages around strengthening community centered health systems, so that members of the public all over the world can understand the issues and causes of injustice. Let’s tell the stories behind numbers in ways that people can understand, communicated in forms they can utilize (clue: not case studies!).

5) Finally, and most importantly, let’s be inspired by people like the volunteers at the COPASAH secretariat in India to be champions, to not give up on what we believe in (for me, social equality, equity and social justice). But let’s also be realistic: Global Health is great for measuring things and improving health security; it is not necessarily the right place for people who want to tackle injustice, and change the world in the many ways it so urgently needs changing.

Denis Bukenya – PHM-Uganda, Human Rights Research Documentation Centre (HURIC),Uganda

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COPASAH Global Symposium 2019 on Citizenship Governance Accountability in Health

Leaving No One Behind: Strengthening Community Centred Health Systems for Achieving Sustainable Development Goals

15-18 October, 2019 – India Habitat Centre, New-Delhi, India

Community of Practitioners on Accountability and Social Action in Health (COPASAH) www.copasah.net in collaboration with its alliances for social accountability and human rights for the health, well- being and dignity of the marginalised is organizing a COPASAH Global Symposium (CoPGS) 2019 on Citizenship, Governance and Accountability in Health from October 15-18, 2019 in New-Delhi, India.  COPASAH is a global community of practitioners who came together in 2011 to learn and share from each other on community led practices around accountability and health governance. In the last few years Accountability and Governance is being increasingly seen as essential to the fulfillment of the Universal Health Care and Sustainable Development Goal agenda. Members of COPASAH are among the leading practitioners of social accountability and community action in the field of Health and as a group have contributed significantly to the emerging discussions on community-centred and citizen-led processes in the field of health. The COPGS 2019 aims to


The theme of the COPGS 2019 is Leaving No One Behind: Strengthening Community Centred Health Systems for Achieving Sustainable Development Goals. It aims to strengthen the solidarity within the community of practitioners, facilitate conversations between practitioners and other key actors like researchers and development agencies and overall stimulate learning which is driven from practice in the field. It will bring together 500 practitioners from diverse social – cultural contexts including COPASAH members from Latin America, Eastern Europe, Sub Saharan African, Eastern and Southern Asia.

The co-organisers  for the Symposium are  People’s Health MovementAzim Premji University – Bengaluru (India)Accountability Research Centre – American University – Washington DC (USA), Institute of Development Studies – Sussex (UK), Global Health Justice and Governance Programme – Mailman School of Public Health, Columbia University New York (USA).


Through the global symposium, COPASAH will deliberate on a set of broad sub-themes which include:

  • Community action in governance and accountability for health systems strengthening: Through the themes the Symposium attempts to position communities and civil society at large as central to the governance and accountability of health systems (both public and private). It emphasises on community empowerment and transformation of the iniquitous power relations between the community and health systems.
  • Improving access to quality health services for the indigenous, excluded, vulnerable communities and those in fragile contexts: Several indigenous, vulnerable and marginalised communities, and those in fragile contexts such as those affected by conflict, displacement or natural disasters face exclusion and discrimination from the policies, programme and health care services. The modalities of exclusion, non-inclusiveness and discrimination are reflected in the health care programmes and policies that are designed and the kind of health care that is made available.
  • Moving forward the agenda for Sexual and Reproductive Health Rights: Sexual and Reproductive health rights are indivisible aspects of human rights, and deeply linked with the fulfilment of all other civil, political, economic, and social rights. Social action for accountability towards sexual and reproductive health rights is gaining momentum; however, it continues to be challenged by marginalisation and repercussions on the basis of gender, caste, disability, and sexuality.
  • Setting the framework and agenda for people centred accountability of private and corporate health care sectors: In an environment where private providers are largely unregulated, and hence are unaccountable either to the citizens or to the government, the accountability deficit continues to deepen, creating significant challenges for patient’s access to quality and affordable care, and preventing redressal of grievances from such powerful institutions. There is a growing demand for ensuring social accountability of the private health care sector, and developing accountable regulatory frameworks to achieve this.
  • Forging alliances between the community and the health care workers: Frontline health care workers – traditional birth attendants, community health workers (CHW), nurses and midwives the foundational building blocks of the health care systems. More often than not, communities and health care workers are made to relate to each other in hostility and antagonism, instead of solidarity, and such fragmentation cumulatively affects the rights of both the communities and health care workers.

The call for participation cum scholarship for the COPASAH Global Symposium is open till February 15, 2019- 5.00pm IST. The application for participation cum scholarship form is available in five different languages including English, Hindi, French, Spanish and Romani.  For more details and updates on the COPASAH Global Symposium 2019 please visit the Symposium website http://www.copasahglobalsymposium2019.net/index.html

Queries regarding the Symposium can be sent to copasahsymposium2019@gmail.com

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Re-thinking Social Accountability through a Power Discourse

Following the path of a good learning organisation, COPASAH undertook a year long journey of reflection on its relevance to the field of accountability and evaluating its own strategic directions and pathways. The process which began in 2016 with the community feedback and strategic directions meeting in Vancouver (November 2017), continued with an external evaluation and a debriefing meeting in Delhi (September 2017). The current issue of COPASAH Communiqué provides the glimpses of this collective introspection, reflection and insights for the future directions.

Such a reflection will be followed up by marshalling the energies to consolidate the central theme of COPASAH, i.e. community centred participatory accountability processes and bottom up knowledge making, through the Global Symposium on social accountability, that will be hosted by COPASAH in February 2019, in New Delhi (India). It will be a unique o p p o r t u n i t y f o r t h e practitioners of social accountability across the global south and supporters of such apraxis from other fields such as academia and research, donor community, global policy bodies and institutions, and human rights based civil society organisations.

The Millennium Development Goals (MDGs) followed by Sustainable Development Goals (SDGs) have rallied the Governments around the world and the civil society to think together and setting collective goals. However, achieving such goals would be highly i m p r o b a b l e , w i t h o u t accountability to such goals and participation of the community. COPASAH firmly believes and would like to reiterate, social accountability is not a ritual or a master-piece that elites and intellectuals can showcase, but is a process of empowerment and reconfiguring power-relations of the community with the structures of power at various levels. We would like to reach out to all friends and associates to be part of the upcoming global symposium to refine and reiterate such a power discourse in social accountability.

ABOUT THE AUTHOR

E. PREMDAS PINTO is the Global Secretariat Coordinator for COPASAH. As an Advocacy and Research Director at Centre for Health and Social Justice (CHSJ), India, he facilitates the thematic area of social accountability with a special focus on processes of community monitoring and accountability in health. He also coordinates the South Asia region for COPASAH. He is a Human Rights advocate and Public Health practitioner- scholar, actively engaged in processes and social justice issues of the the communities of Dalit Women, rural unorganized labourers and other disadvantaged communities for the last 22 years. To know more about the work of CHSJ and COPASAH please visit, http://www.chsj.org and http://www.copasah.net

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Social Accountability: A Process Oriented Community Practice

THE accountability discourse is gaining momentum globally. However, the dominant discourse of accountability continues to be instrumentalist in its approach, which sees it as a technical report at the worst or merely as an intervention to improve health sector performance, at best. It is also tagged to efficiency, defined as value for money or getting things done at very low financial inputs. To this end, goals without fundamentally touching the core of accountability are set. The language that couches these goals is largely apolitical in its expression. The goals set in this school of thought range from producing a report or a score card to setting the millennium development (MDG) or sustainable development goals (SDG).

When the time-period set is complete, as it happened in the MDGs, question was not asked as to why these goals were not met or what the processes that achieved some of the goals are. It simply, moved to setting another set of goals, i.e. SDGs. Even at a micro level, CSOs which implement projects on community participation tend to follow such trends by developing score cards or technical reports, over and over again.

However, at the core of accountability practice the thrust is on questioning of inequity, inequitable distribution of resources and the skewed power relations which keep citizens or communities perpetually in a state of frustration. It also aims at changing the iniquitous power relations of the health system with the communities. COPASAH has foregrounded the community centred accountability practice which is process oriented that aims to change the power asymmetry of the community with the health care system. Such processes are aimed at advancing human rights of the marginalized with a broader
framework of realizing equity and social justice.

This COPASAH Communiqué highlights the process oriented community practice of social accountability. For practitioners of accountability, as highlighted in these stories of practice, accountability is not a finished product. It is a continuous iterative process of engagement, mobilization, strengthening community’s power and their ability to question and change things with multiple contextualized methods and tools, as well generating voice and participation.

 

ABOUT THE AUTHOR

E. PREMDAS PINTO is the Global Secretariat Coordinator for COPASAH. As an Advocacy and Research Director at Centre for Health and Social Justice (CHSJ), India, he facilitates the thematic area of social accountability with a special focus on processes of community monitoring and accountability in health. He also coordinates the South Asia region for COPASAH. He is a Human Rights advocate and Public Health practitioner- scholar, actively engaged in processes and social justice issues of the the communities of Dalit Women, rural unorganized labourers and other disadvantaged communities for the last 22 years. To know more about the work of CHSJ and COPASAH please visit, http://www.chsj.org and http://www.copasah.net

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COPASAH SOUTH ASIA EXCHANGE AND STRENGTHENING MEET ON SOCIAL ACCOUNTABILITY IN HEALTH IN THE SOUTH ASIA REGION DECEMBER 4-6, 2016; KATHMANDU, NEPAL

INTRODUCTION

COPASAH – Community of Practitioners on Accountability and Social Action in Health – is a global community of practitioners who share a people –centric vision and human rights based approach to health, health care and human dignity ( http://www.copasah.net). COPASAH’S mission is to nurture, strengthen and promote collective knowledge, skills and capacity of communityoriented organisations and health activists primarily in the regional nodes of South Asia, Latin America, East Southern Africa and Central Europe working in the field of accountability and social action in health, for promoting active citizenship to make health systems responsive, equitable and people-centred.

CONTEXT FOR THE MEET AND STRENGTHENING SOCIAL ACCOUNTABILITY IN
SOUTH ASIA

In the COPASAH South Asia regional node of practice, synergy has been enhanced through
different interactions in form of workshops, Facilitated learning exchange visits and through virtual communication on the communication platforms and the COPASAH Communiqué (newsletter).At country level this has deepened but there are very few opportunities for collective deliberations on the social accountability in the region in form of face to face meetings. With a view to understanding various approaches and experiences from a range of health rights organizations and health rights activists in different countries of South Asia (India, Pakistan, Nepal and Bangladesh), COPASAH South Asia envisaged a platform for discussion to contribute to strengthening the field of accountability in health in South Asia and to deepen and expand the regional base further of COPASAH through medium of a COPASAH South Asia strengthening meeting. The objectives of the meet were:

OBJECTIVES:

  • To understand the eco-system of social accountability in health in the South Asian
    Countries
  • To facilitate mutual sharing of experiences and learning from each other
  • To strengthen South Asian solidarity to promote people oriented social accountability
    perspectives and perspectives.
  • Explore opportunities for knowledge production from accountability practice in the
    region and its exchange in form of webinars, case studies and other mediums

SESSIONS OF THE MEET

COPASAH South Asia Exchange and Strengthening Meet, was convened in Kathmandu, Nepal from Dec 4 to 6, 2016 on a very participatory note. The meet saw significant participation from countries of Srilanka, Bangladesh, Pakistan and Nepal. The meet was facilitated by COPASAH Steering Committee (SC) member Renu Khanna, with co facilitation support from COPASAH South Asia SC member Gulbaz Ali Khan.

DECEMBER 5, 2016 SESSIONS

SESSION I: MUTUAL INTRODUCTIONS, CONTEXT OF THE MEET AND COMMON
EXPECTATIONS FROM THE MEET

Representing the COPASAH South Asia practice node Surekha Dhaleta set out the tone for the South Asia meet. Through a participatory methodology COPASAH SC member Renu Khanna steered the mutual introductions, wherein the participants shared the context of their work and affiliated organizations. Representing Srilanka Dr. Harishchandra Yakandawala and Asitha Punchihewa from Family Planning Association (FPA) of Srilanka; Tharindu Gunathilaka and Sanath Mahawtihanage from the Sarvodaya Sharmadana Movement of Srilanka, elucidated that Sarvodaya is the biggest Non-Government Organisation in Srilanka and the organisations including FPA and Sarvodaya have been instrumental along with other stakeholders in proposing Health as a Right and Srilanka may soon recognize health as a Right in its Constitution.

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Representing Pakistan, Kanwal Iqbal from Community Uplift Programme (CUP) and Gulbaz Ali Khan from Centre for Inclusive Governance (CIG) highlighted that CUP has been amongst the forerunners in carrying out social accountability in Pakistan and both the organizations have experimented with use of community score cards in family planning, citizen report cards in the Khyber Pakhtunkhwa region of the country as well have had experience of experimenting with other strategies like that of budget tracking, Right to Information, Right to Public Services and developing manuals, guidelines etc. for health services providers also. Amongst the Nepal representatives, Narayan Adhikari from the Accountability Lab outlined that the organization is working towards accountability, health and migration in Nepal and is geared towards using Information Communication Technologies (ICTs) extensively with youth in Nepal. Post the April, 2015 earthquake in the country, the Accountability lab has set up citizen help desks to bridge gaps with local people on the ground and the organization has bolstered campaigns such as the Integrity Idol since 2014 to debate around the idea of integrity and demonstrate the importance of honesty and personal responsibility. Kedar Khadka from GoGo foundation in Nepal elaborated that GoGo foundation has been instrumental in conducting public hearings from village, district up to central level, and in developing social audit accountability tools which have been adopted by Ministry of Health education and other sectors also. Two participants from Nepal, Rakshya Paudyal from Beyond Beijing Committee (BBC) in Nepal pointed out the 8 BBC and Kapil Kafle, coordinator Men Engage Alliance South Asia joined the meet later in the day. Representing Bangladesh, Rowshan Ara and Maksuda Khatun from Naripokkho outlined that the organization is women’s activist organisation working for the advancement of women’s rights and entitlements and building resistance against violence, discrimination and injustice. They delineated that Naripokkho was found in 1983 and since then has been involved in numerous activities related to Violence Against Women (VAW) in Bangladesh, which include campaigns, cultural events, training, research, lobbying and advocacy. It has also vast experience in monitoring government health care facilities and in increasing accountability of service providers amongst the key components of work on monitoring, they added.

COMMON EXPECTATIONS FROM THE MEET

Advancing from formal introductions by participants around the context of their work and of their organizations, the schedule was elucidated by Renu Khanna, following which the
participants outlined their common expectations from the meet. The potentials from the meet by the invitee participants were outlined, in terms of taking it as an opportunity to understand health related issue in the South Asian countries, besides exploring it as a platform of experience sharing on challenges and success of accountability practices, and learning from each other on accountability tools, as well taking it a prospective instance to know more about COPASAH, forge cross country alliances with different organisations, networks and strengthen the COPASAH network in the South Asia region.

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COPASAH SC member Renu Khanna introducing the schedule of the meet

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Roma Minority and Social Accountability in Macedonia

copasahRoma minority in the countries of the South Eastern European region represents the most marginalized minority of people who live in unfavorable social and economic conditions compared to the general population. Roma people are deprived in many spheres of their lives, including housing, education, employment and health, access to health care and discrimination in health care settings. Social determinants of health have especially negative influence on Roma health, including but not limited to poverty, social exclusion, low level of education, to name a few, thus resulting in poorer health outcomes among Roma in comparison to the rest of the population in the region. For example, estimates are that the life expectancy among Roma in average is 10 years shorter in the region, with infant and maternal mortality rates higher among Roma. There is a an absolute lack of health statistics segregated by ethnicity, as well as absence of relevant research studies conducted and/or developed by competent state institutions. This leads to the fact that the data on the many public health conditions among Roma people are solely based on the research reports conducted by Civil Society and international institutions. Additionally, the lack of data aggravates the health condition since the states do not have comprehensive data as guidance for policy planning and implementation. In order to improve the conditions of Roma minority the countries from the region in 2004 signed the Declaration for the Decade for Roma Inclusion for the period 2005 – 2015 and made a commitment to undertake measures to improve the conditions of the Roma minority. Yet although a decade has ended, there is no significant improvement in the status of Roma minority in the countries of the Region. This is due to the lack of political commitment and funding for the adopted policies aimed to improve the status of the Roma people.

Roma Integration 2020 is a new initiative for improvement of the condition of Roma people, initiated by the European Union.

In Republic of Macedonia, the official census data, which is 14 years old shows that the Roma represents 2.6% 2 to 6% of the population, yet the findings of the civil society organizations shows that this number is much higher and probably reaching 5% to 6% of the population. The situation about Roma minority in South Eastern Europe described previously is also valid for the Roma minority in Macedonia.

Social accountability

Social accountability for the improvement of Roma health was initiated in Macedonia in 2009, by the Association for Emancipation, Solidarity and Equality of Women (ESE). ESE is funded by the Open Society Institute and Foundation Open Society Macedonia,that aims to
improve the health status and immunization of Roma children. In 2011, the Government for the first time allocated funds specifically aimed for Roma in one of the preventive Programs under the Ministry of health. This was the result of the work initiated with the process of applied budget work, advocacy and civil society participation.

The activities included: health education of Roma people, increased number of visits of community (patronage) nurses to Roma women during the period of pregnancy and one year after the delivery of the child, along with measures for active identification and immunization of non-immunized Roma children. In order to strengthen the demand for
health rights and entitlements, civil society organizations (ESE, KHAM, CDRIM, LIL and Roma SOS) started to implement community monitoring work.

Through this work Roma communities where strengthened such that they received the rightful entitlements through the Programs for preventive health care of mothers and children. Later on, community monitoring work was expanded to include examining
the policies for improvement on reproductive health of women, specifically for the Program for cervical cancer screening . Furthermore, the Civil Society Organisations (CSOs) added the social audit methodology into their work.

Parallel budget monitoring work was conducted in order to track the budget allocation and execution for the foreseen measures aimed for Roma. The entire work was followed with
advocacy efforts at the national and local level. The community took an important role especially in the local level advocacy process.

Many challenges were detected that related to the national level implementation of the activities aimed for Roma, including insufficient budget allocation , frequent amendments of the Program(annual budgeted program under the Ministry of Health) during the fiscal year, lack of capacities of the public health institutions to deliver the services, lack of oversight mechanisms as well as  lack of transparency and accountability especially within the Ministry of Health. Community monitoring on local level showed how the problems detected on national level influence on poor service delivery at the local level. The findings from the Roma communities showed that the foreseen activities, like additional visits by patronage nurses in Roma families or educational activities for chilld’s health and immunization are not implemented and does not reach the Roma people. Yet this process empowered Roma people to take ownership of their rights and entitlements and for the first time it enabled them to proactively demand fulfillment of their rights from the health care providers . The majorimpact is seen in the increased immunization coverage rates of Roma children that is a result of the proactive demand from the Roma communities and not a result of the measures foreseen by the Ministry of Health.

Today they are empowered to take a rights based approach to securing their health needs. It is heartening to see that Roma people have started to voice out their dissatisfaction from the services provided, in comparison to the previous time where they felt disenfranchised. Today they demand higher quality of services. Coordinated advocacy at the national and local level has resulted in better functioning of health centers, building infrastructure and equipment, refurbishment and vehicles.

Today, ESE has initiated its work to improve transparency and accountability with the Ministry of health, continuing its work for the demand of the fulfillment of the needed services.

The groups of CSO (ESE, KHAM, CDRIM and RRC) are continuing their social accountability work in order improvement of the health and access to health services for Roma minority in Macedonia.

About the Author
Borjan Pavlovski is the coordinator of the program for public health and women’s health in Association for Emancipation, Solidarity and Equality of women in Macedonia ( ESE). ESE develops and assists the women’s and civic leadership (especially that of Roma community) for development and implementation of human rights and social justice in Macedonia using approaches of monitoring and budget analysis, monitoring of human rights and providing assistance and information.

ESE primarily focuses on meeting the urgent needs of citizens, in particular the vulnerable groups of citizens, and on influencing the creation of long-term changes. ESE also provides legal and paralegal protection, as well as information to different categories of citizens and introduces them with the possibilities for protection of their rights. For more details on ESE
please see: http://www.esem.org.mk/en