COPASAH Thematic Hub Reproductive Health: The Need to Stimulate Community Action and Accountability
The Logic - Maternal Health and subsequently Family Planning have emerged as a blue riband component of global health programming. In the years leading to the Millenium Development Goals, reduction of Maternal Death became a key indicator of improvements both of population level health as well as health systems. Childbirth conducted by skilled birth attendants or in hospitals as well as provision of emergency obstetric care when necessary were seen as key interventions and considered indicative of a health system which is caring, prompt and competent. Multiple systems for promoting the provision of appropriate service, as well as monitoring progress were established through mechanisms like the Partnership on Maternal Neonatal and Child Health (PMNCH) headquartered in WHO, Maternal Health Task force headquartered in Harvard University, the Countdown to 2015 as well as WHO Commission on Information and Accountability (CoIA) on Women and Children’s Health and the UN sponsored movement Every woman Every child focused on women’s children’s and adolescents health. A large number of international agencies, bilateral donors and private philanthropies provided funds and other support. Many INGOs, Universities and in country organistions were involved in a multitude of activities to bring about changes. As a result of the intense focus on maternal health there was a considerable reduction of maternal deaths world-wide even though only a handful of countries were actually able to reach their MDG. Despite a 44% reduction in MMR over the MDG period the global MMR continued to be unacceptably high at 216 deaths for every 100,000 live births .
In the SDG paradigm maternal healthhas lost its primacy but remains an important component of the overall health indicator. The indicator goes beyond the reduction of Maternal Mortality Rate of 100 to 70 deaths per 100,000 live births. At the same time coverage, quality and financial protection are key to the Universal Health Care approach promoted through the SDG target 3.8. While the idea of health system strengthening finds adequate reflection, the thrust on community engagement and ownership is not well articulated in the SDG approach. The overall process of preparation towards SDGs was more consultative and there was some level of participation of INGOs and national NGOs in this process, but the idea of community engagement does not get reflected. Today nearly two years after the SDGs have been adopted, the information about SDGs are slowly being shared among the public, civil society organisations and community based organisations. A multi-stakeholder Global Partnership for Sustainable Development Data has been established which includes Governments, businesses as well as larger NGOs. However if the SDGs have to reach the last mile and include the most marginalized, this approach which appears mostly based on a concept of ‘stewardship’ may not be enough. The current approach is based on the Government partnering with International agencies, philanthropies, business and large social service NGOs to delivery services to alleviate poverty and address other key social and environmental issues. The role of communities is seen as passive recipients and beneficiaries. However a more comprehensive approach to development cannot ignore issues of autonomy, self-determination which are central to human rights and participation in governance which is essential to sustainability.
Two highlights of the final Countdown to 2015 report relate to inadequate coverage of key interventions and lack of equity with pro-rich gaps for most indicators.If these two gaps have to be addressed it is essential to involve communities. At the same time experiences from India and elsewhere have drawn attention to the widespread prevalence of disrespect and abuse – which is primarily for marginalized communities. Writing in the Lancet in 2014, Lynn Freedman calls this a blind spot saying it “is indeed an appropriate metaphor for the way that disrespectful and abusive treatment (D&A) of women during childbirth in facilities has evaded the attention of the global health community and of national and local health authorities, including those governing midwifery and other health professions, in countries worldwide, both rich and poor.” She goes on assert that it is not an isolated phenomenon but rather a deep malaise within maternity health services. She sees this as a crisis in the health system and indicates very poor system accountability. A recent Lancet Review published October 2016 draws attention to the importance of quality equity and dignity in maternal health services and the need to address all women everywhere within its ambit. Critiquing the current approach Lynn Freedman has emphasized on the need to look inwards towards its citizens rather than copy each other’s policies and approaches. In terms of solutions Lynn Freedman suggests it is important to do more grounded research and for increased South to South learning and calls for robust social accountability measures to be put in place.COPASAH is in a unique position to push this agenda forward as not only does this approach harmonise with this call but many COPASAH members are engaged at the cutting edge of social accountability practices around maternal health in different contexts.
In many ways Lynn Freedman’s paper of October 2016 in the Lancet provides a lucid articulation and justification of why COPASAH needs to actively engage with the issue of Maternal Health. However a similar situation exists in the field of Family Planning or Contraception. Since the establishment of the FP 2020 initiative by donors like BMGF and DFID, globally many more countries have upscaled their family planning programmes. The issue of coercion, and poor quality has been consistently highlighted in the past and were key to the discussions of ICPD ( International Conference on Population and Development 1994). The FP programmes in India and Peru ( under Fujimori) have been internationally decried. In the last ten years stories of forced sterilization has re-emerged as an issue in Eastern Europe ( with Roma communities) as well as Africa around PLHIVs. A campaign against coercive sterilization was conducted which led to global institutions like UN Agencies ( 2014) and FIGO (2011) adopting guidelines and statements around forced/ involuntary sterilization and need for strict quality assurance . With the renewed emphasis on Family Planning programming the issue of quality and coercion have become importance once again and it is necessary to draw attention to social accountability as a key mechanism guard against any form of coercion, disrespect and poor quality which form a continuum. Organisations like IPPF and Population Council have already started exploring the issue and COPASAH members like CHSJ have already been successfully testing out approaches in the field. COPASAH Reproductive/Maternal Health Thematic Hub – The idea of accountability has been accepted within the reproductive health within the overall framework of evidence based practice and the need for data for monitoring progress is acknowledged. However the importance of involving the citizens or the communities who experience the services is still not universally seen as important. There is much greater emphasis on ‘fixing’ the inputs – eg. human resources and technological options etc. Even when acknowledging poor quality and disrespect, the idea of involving citizens as the main stakeholders of this process is not being considered. Considering the existing work of COPASAH in this field it is important that COPASAH engage more vigorously in promoting the practice of social accountability in different ways. Key players who have been promoting social accountability in the maternal health field and in the development domain like Lynn Freedman and Jonathan Fox are already active members of COPASAH and keen to work with us to take this issue forward. Similarly members from other global civil society alliances like People’s Health Movement (PHM), International Initiative of Maternal Health and Human Rights (IIHMMR), Equinet etc. are already members of COPASAH. This will enable COPASAH to pull together and contribute to an effective call to incorporate Social Accountability into existing MH and FP related policies and programming . Objectives of the Thematic Hub:
Highlight gaps in last mile programming and adverse effects on marginalized communities with respect to maternal health and family planning programming
Share and highlight existing innovations to promote participation and social accountability in the field of maternal health and family planning programming among practitioners, INGOs, Researchers, donors, technical agencies and other global actors
Advocate for greater incorporation of participatory methodologies to strengthen health system planning, implementation and monitoring for developing appropriate and effective reproductive health care to communities.
The hub will interface with the two other proposed thematic hubs of COPASAH on i) Indigenous Populations and ii) Private Sector in Health Some of the activities that could be taken to create a momentum around these issues could be
Identify key practitioners and academics who have been raising the issue of disrespect and abuse around SRH services in respected institutions as well as field based organisations in South Asia, Africa, Latin America and in Eastern Europe.
Contact these individuals and organisations to understand their concerns and share our concerns and experiences. Develop a wider stakeholder group on this issue.
Organise/find opportunities for a consultation with the key stakeholder group to develop a plan for advocacy
Highlight the practices of COPASAH members through COPASAH communication channels
Interact with key policy influencer agencies and platforms drawing attention to COPASAH member practices
Create opportunities of partnership between field practitioners with academics for collaborative research/ papers/joint publications etc drawing attention to the importance of social accountability in global RH field
Some of these steps are being taken informally by individual COPASAH members, but a COPASAH hub would enable these actions to take place in a coordinated manner creating greater impact and yield better results.