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.
COPASAH (Community of Practitioners on Accountability and Social Action in Health) had a significant presence at the Fourth Global Symposium on Health Systems Research (GSHSR), 2016 convened from November 14-18 at the Vancouver Convention Centre, in Vancouver, British Columbia, Canada.
Since the inception of Community of Practitioners on Social Accountability and Social Action in Health (COPASAH), the East and Southern Africa (ESA) member institutions have registered achievements as individual initiatives owing to the knowledge acquired from Facilitated Learning Exchange Visits. However, the COPASAH ESA membership has experienced limited engagement among members thus affecting further growth both in terms of membership and ideas for advancement of the network.
The Coalition for Health Promotion and Social Development (HEPS UGANDA) Uganda is successful in implementing the Citizen’s Engagement initiative to Stop Medicine Stock Outs (COME) that aims to fostering action, engagement and participation of the community. This initiative which was kick started in March 2014 has today shown that the community engagement can increase social accountability. Community leaders are forging a path towards advocacy of health rights for all. This includes ensuring every citizen has access to essential medicines in every public health facility, where the availability of essential drugs is adequately provided and above all health care services are improved to serve the community.
The focus of the initiative was to get the public health facilities in Lira and Kiboga districts up to health care standards. Citizen Report Card (CRC), a social accountability tool was used to provide feedback received from the users of public services to the public health agency. The feedback was received through the sample surveys that were conducted on different aspects of service quality. This enabled the public agencies to identify strength and weaknesses in their work. The CRC was further used to identify key gaps, with a way-forward, a plan to fix the gaps that came up during the discussions between the community, service providers and duty bearer.
A woman drops a suggestion in the suggestion box that was provided during the implementation of the community action plan. This resulted in community dialogues and interface meetings at Katwe HCIII, Dwaniro Sub County, Kiboga District.
The Uganda Government recognizes the importance of community involvement in the successful fulfillment of the right to health. The National Development Plan (NDP), the overall Government development strategy, sets and prioritizes the empowerment of individuals and communities for a more active role in health development and the implementation of the Uganda National Minimum Health Care Package (UNMHCP).
During the project life-cycle, it was heartening to see collective action at work, especially when a community gets together to demand for their entitlements. Such is the chronicle of the residents of Dwaniro Sub County, Kiboga District, who observed that a lack of adequate and standard infrastructure compelled them to lobby for a positive change in the status of their health centre, eventually achieving 50% of service enhancement of what was originally targeted.
In Kiboga District, inadequate infrastructure is affecting access to services in all the health facilities. For example, the district hospital is a 100 bed capacity but the intake of patients is over 150 which puts the pressure of hospital management at risk. This means that the current ward capacity which has limited capacity cannot match with the volume of admissions. It is often a common sight to see patients sleeping under beds, or in the veranda. Male and female patients are put-up in the same ward. These are reasons to believe that the health consumers are shunning away from public health facilities as they lack adequate care. The community work experience in Dwaniro Sub County is an ideal example to showcase how monitoring service delivery can yield positive outcomes through the process of social accountability and community participation. During the interface meetings facilitated by HEPS Uganda between the health workers, community leaders and community members in the last quarter 2014, Katwe community members identified issues that were affecting their health centre and these were prioritized in the community action plan. The health centre lacked a clear complaint and redress mechanism, a placenta pit, and had poor accommodation facilities for staff. The General ward and OPD department were of substandard, a situation that had affected the access to services in this health facility.
The community members of Dwaniro Sub County in collaboration with the health unit management committee members and the health facility in-charge agreed to submit a proposal to the sub county, district headquarters, politicians and development partners to solicit for support to improve the health facility infrastructure. In addition, community fundraising conferences were held to supplement the development works at the health centre.
The district councilor Nelson Agaba, informed community members of Dwaniro Sub County during a quarterly community action plans review meeting that due to the lobbying, the staff quarters were included in the district work plan for the year 2015. In this regard, through community fundraising meetings, the community members also contributed money, bought building materials to help in the construction of the health workers staff houses.
The health centre beefed up its health education programmes to keep to the goal of information dissemination, now to include health rights and responsibilities of clients and the use of rational medicines among others.
In Uganda, the range of health services varies with the level of care in public and private health facilities. Public health facilities up to Health Centre III (HCIII) offer basic services as per the minimum health care package. HCIIIs in particular the lowest facilities accessed at village level render a comprehensive health care package. At HCIIIs there are provisions for laboratory services for diagnosis and it is the first referral cover for the sub county as the third lowest unit of local government. But, access to services in these health facilities is limited due to a number of factors such as sub-standard health care facilities, unavailability of drugs and lack of awareness of community about their rights and standards of service.
Healthcare promotion in Uganda is strongly dependent on availability of adequate infrastructure, facilities, and technology. To a large extent, the infrastructure, equipment, furniture and vehicles define the capacity of a health centre to deliver health services to the population. However the state of the current infrastructure is below the standard of the adequate infrastructure set by the Ministry of Health.
Joan Esther Kilande holds a bachelor’s degree in Social Sciences and majored in Gender Studies. She has a certificate on Primary Health Care. She has certificates in Reproductive Health and Human Rights, Policy advocacy and Social media campaigns. She has been working with Journalists for the last 5 years in various health and human rights campaigns and has skills and experience in using social accountability approaches specifically the Citizens Report Card (CRC), Community Score Card (CSC) and the HEAR model.
Wakabi Eric is an all-round communication specialist and journalist with more than three years of experience in, health policy advocacy and communicating development issues to various Newspapers, Magazines, and Internet Productions, NGOs in Uganda and South Sudan. He holds a B.A Mass Communication degree of Makerere University and currently pursuing Bachelor of Laws at the same University. He’s currently a communications officer at HEPS –UGANDA
The Training and Research Support Centre (TARSC) and Zimbabwe Association of Doctors for Human Rights (ZADHR) has reported on different platforms of COPASAH and in the COPASAH Communique earlier, as how Participatory Action Research (PAR) was used in the Cassa Banana community to explore, analyze and take action on priority health problems faced by the community. PAR activities led to the formation of a Community Health Committee (CHC) and the development of a community action plan that prioritized lack of clean water and poor sanitation as the key health problem in the area. Initially, the CHC focused on clarifying the confusion in roles and responsibilities between two district councils, both of whom denied responsibility for supporting Cassa Banana. More recently, the CHC has focused on organizing community actions and engaging with the relevant duty bearer in demanding the delivery of basic services, including access to health services, waste collection, and the improvement of sewage and water supplies.
Cassa Banana is one of many informal settlements that have sprung up around Harare, the capital of Zimbabwe, over the last 20 years or more. In most cases, these unplanned urban settlements are overcrowded, lacking in basic infrastructure and services, with poor environmental conditions for health. Residents are facing a range of other social and economic challenges common throughout the country, including rising urban poverty, falling access to improved water and sanitation, and lack of overall growth in the economy, employment or household incomes post 2013 (TARSC and MoHCC Zimbabwe Equity Watch 2014). The current Public Health Act has provisions for addressing water and sanitation but these are poorly implemented with an underfunded public health system. Diarrhea, intestinal infections and periodic outbreaks of cholera are not unusual in settlements such as Cassa Banana.Despite these challenges, there are opportunities for health and social accountability. The right to health care, water, food and shelter was included in the new Constitution of 2013.
Zimbabwe has seen improvements in the Human Development Index mainly due to better health and HIV outcomes, as there is sustained gender parity in education. Improvements in health and well being in Zimbabwe depend, among other things on engaging with the strong social assets within and improving dialogue between communities, state and private sector, in raising and addressing barriers to resources and services for health, and in supporting community efforts to define and act on problems in order to transform their own environments.
An aerial view of Cassa Banana © L. Dhumukwa 2015
Within this context, the work in Cassa Banana is building a body of knowledge on strategies to support community efforts to take action and on how to hold duty bearers accountable. As part of this process, in October 2015, nine community members were trained as community photographers using a PAR tool called Photovoice.
-COPASAH at the Learning Exchange: Transparency/Accountability Strategies & Reproductive Health Delivery Systems- Accountability Research Centre, School of International Service (American University), Washington DC
A Learning Exchange on Transparency/Accountability strategies and reproductive health delivery systems was recently held on June 27 and 28, 2016. This learning exchange was convened by Accountability Research Center, School of International Service, American University along with the Evidence Project, International Planned Parenthood Federation and Reproductive Health Supplies Coalition, Advocacy and Accountability Working Group. COPASAH was represented at the learning exchange meeting by two Steering Committee members including Walter Flores (CEGSS, Guatemala) and Renu Khanna (SAHAJ, India ) – and E. Premdas Pinto from t h e COPASAH Global Secretariat, Centre for Health and Social Justice(CHSJ, India
The learning exchange was convened in the background of systemic weaknesses, vulnerabilities and biases which at different points in health systems form bottlenecks for the reproductive health (RH) supplies to reach the last mile. Practitioners, researchers and persons involved in the field of Transparency, Participation and Accountability (TPA) participated in the learning exchange. The goal of this learning exchange was to inform and identify practical strategies to address unidentified and unmeasured bottlenecks in the process of procuring and moving commodities through the supply chain into health facilities at different levels as well as the barriers that impede citizens’ enacting of full, free and informed contraceptive choices. One key proposition for discussion was the issue of public monitoring which can inform problem solving and policy advocacy, while problem-solving or advocacy strategies can in turn inform monitoring strategies.
The objectives of the learning exchange were set as follows:
- Share analytical insights, key concepts and practical developments both from transparency, participation and accountability and the reproductive health systems, including commodity security;
- Learn from experiences by addressing issues of supply chain challenges in various sectors
- Identify research gaps and/or questions for addressing the monitoring challenges involved in tracking the determinants of access to contraceptive services;
- Contribute to practical research agendas;
- Discuss possible strategies for improved monitoring through collaboration and sharing between RHSC and TPA sectors.
Presentations: COPASAH members made presentations on various experiences of practice of citizen empowerment and monitoring. In the session ‘Key concepts and lessons from the emerging field of Transparency, Participation and Accountability’ which was chaired by Kelsey Wright, Evidence Project, E. Premdas Pinto from COPASAH Global Secretariat, CHSJ, made a presentation and shared the experiences of COPASAH strategies of bottom up accountability practice, networking of practitioners, using ICT for networking and advocacy for the citizen centric accountability practice. This session introduced some key concepts and lessons emerging in the TPA field and used concrete examples of how they have been applied in different sectors and to what effect. This included approaches to advocacy, problem solving and policy monitoring.
E. Premdas Pinto, COPASAH Global Coordinator, in his presentation highlighted the issue of bottom up knowledge generation from practice to countervail the top-down model of knowledge making and policy making. The contributions of COPASAH in terms of issue papers, case studies, stories of practice from various countries were highlighted. COPASAH knowledge products were also distributed to participants.
Renu Khanna, COPASAH Steering Committee member, from SAHAJ Society for Health Alternatives (India) presented her reflections on challenges faced in independent monitoring of maternal and reproductive issues. These challenges were encountered in initiatives dealing with social autopsies of maternal deaths, monitoring negligence and denial of services to women through various community based efforts. This presentation was made as part of the session on ‘Challenges of independent monitoring and advocacy’. The session aimed at sharing experiences and reflections of practitioners who have been combining monitoring and advocacy to advance health rights. This session was chaired by Sono Aibe, Pathfinder.
Walter Flores, COPASAH Steering Committee member, from Center for the Study of Equity and Governance in Health Systems (Guatemala) presented the citizen monitoring and community ethnography undertaken in Guatemala. The process was presented through a documentary followed by a presentation. Both visual presentations brought out the centrality of citizen empowerment, forming collectives and strengthening citizen voice as a sine qua non for monitoring and people centred advocacy. They also highlighted that when citizens voice critical questions, the system is likely to resist and also that there is possibility of back lash.
Conclusion: The small group discussions from the learning exchange deliberated on the critical research that would bolster the monitoring of reproductive health care and access to services. The themes of power, the research questions to be asked, various strategies that could be combined both at the grass roots as well as policy making level for improving access to reproductive health care, were also discussed.
About the Authors
- Premdas Pinto coordinates the Global Secretariat for COPASAH.
Renu Khanna and Walter Flores are the Steering Committee members of COPASAH Global.
The health and nutrition accountability sector in South Asia is a rich and vibrant field, with a great deal to offer in terms of innovation and best practice – but it still performs relatively poorly on health and nutrition indicators.
A range of accountability initiatives have been implemented in the health and nutrition sector, including techno-managerial, transparency oriented, participatory and collective or social accountability initiatives, but there is little work yet that is taking both a comparative and theoretical perspective to ground existing and future initiatives on accountability, and accountability in health in particular.
In March 2016, in partnership with the Community of Practitioners on Accountability and Social Action in Health (COPASAH), the project convened an online expert discussion which brought together 49 practitioners involved in improving health and nutrition services in South Asia. They shared their experiences on community participation and engagement, negotiating with the state, private sector accountability, and how to define and measure impact.
The learning they shared included the following:
- A ‘culture of questioning’ is crucial to mobilising communities around social accountability in healthcare.
- The effectiveness of social accountability tools – online or offline – depends on the way they are used. Part of their value is that they create an environment where people can sit together and start talking about healthcare issues.
- Clear, attainable goals are essential to ensure community participation.
- When locally-collected data are used to push for better service delivery at ‘higher’ levels of government, the voice of community members becomes more legitimate.
- Lack of regulation in the private sector means there is no effective framework for accountability in service delivery.
- It is essential to put politics and power at the centre of the accountability discourse, to make sense of the changes we seek to create.