This report was written as a background document for the convening: “Practitioners Convening on Community Monitoring for Accountability in Health”, which was held in Johannesburg, South Africa from 18th – 20th July 2011. The convening was organised by the Accountability and Monitoring in Health Initiative (AMHI) of the Open Society’s Public Health Program (PHP), in close collaboration with an advisory group1 of four experienced practitioners from Guatemala, India and Zimbabwe.
In sub-Saharan Africa, low taxes co-exist with even lower government accountability, seen in high levels of corruption and low public goods provision. While there are existing theories of why taxation might be linked to better governance, many of the microfoundations of this effect remain unclear. I argue that taxation impacts governance by altering the expressive benefit citizens receive from sanctioning corrupt officials, making those who pay taxes more likely to hold leaders accountable. I provide new cross-national evidence that taxation and corruption are linked; I then formalize the theory and test the proposed mechanism using a set of laboratory-in-the-eld experiments in Uganda. I find evidence that taxation activates a stronger fairness norm, leading citizens to demand more from leaders. This effect is strongest among adult, wage-earning men – exactly the group who has the most experience, historically, paying taxes in Uganda. I then propose additional tests, to be carried out in 2013, to strengthen and expand my findings.
We continue our exploration of community participation in Africa, 25 years after the Bamako Initiative. Dr. Frederick Golooba-Mutebi is a political scientist and Honorary Senior Research Fellow at the School of Environment and Development, University of Manchester and Research Associate of the Africa Power and Politics Programme at the Overseas Development Institute in London. He has widely published on health, local government and other topics, with a concentration on Uganda, Rwanda, South Sudan and South Africa. (Cross-posting from HFA Blog)
This annotated bibliography was prepared as a resource for people working on different dimensions of social power, social participation and social accountability in health. A universal health system values and ensures the right to health care, entitling all citizens in a country to access the same range of services according to their need and pay for these services according to their income. Achieving this calls for more than technical solutions. It demands public leadership and people’s power to assert social needs and interests, to influence the allocation of societal resources towards health needs and to challenge the distribution of power and resources that block this. Social power, participation and accountability are thus central concepts in building people centred health systems.
Current methods for estimating maternal mortality lack precision, and are not suitable for monitoring progress in the short run. In addition, national maternal mortality ratios (MMRs) alone do not provide useful information on where the greatest burden of mortality is located, who is concerned, what are the causes, and more importantly what sub-national variations occur. This paper discusses a maternal death surveillance and response (MDSR) system. MDSR systems are not yet established in most countries and have potential added value for policy making and accountability and can build on existing efforts to conduct maternal death reviews, verbal autopsies and confidential enquiries. Accountability at national and sub-national levels cannot rely on global, regional and national retrospective estimates periodically generated from academia or United Nations organizations but on routine counting, investigation, sub national data analysis, long term investments in vital registration and national health information systems. Establishing effective maternal death surveillance and response will help achieve MDG 5, improve quality of maternity care and eliminate maternal mortality (MMR ≤ 30 per 100,000 by 2030).
Improving the quality of care is essential for achieving reductions in maternal mortality. Audit is one of the methods which can be used to simultaneously assess as well as improve quality. This commentary discusses one type of audit--confidential enquiries into maternal death. We believe that the enthusiasm for establishing a confidential enquiry system in Nigeria is growing. The challenges faced in setting up an audit system are discussed and 6 steps are proposed to locate the conduct of a confidential enquiry as part of a set of activities which will take cognizance of existing know-how, create shared ownership and provide a coherent picture of needs and information gaps in the provision of quality maternity services. Having such a system in place can be a route towards achieving a progressive vision of accountability for the reduction of maternal mortality in Nigeria
This study of current infection control procedures and practices during labour and delivery in health facilities in Gujarat revealed a need for improved information systems, protocols and procedures, and for training and research. Simply incentivizing the behaviour of women to use health facilities for childbirth via government schemes may not guarantee safe delivery.
The Millennium Development Goal 5 - reducing maternal mortality by 75% - is unlikely to be met globally and for the majority of low-income countries. At this time of heightened concern to scale-up services for mothers and babies, it is crucial that not only shortfalls in the quantity of care - in terms of location and financial access - are addressed, but also the quality. Reductions in maternal and perinatal mortality in the immediate term depend in large part on the timely delivery of effective practices in the management of life-threatening complications. Such practices require a functioning health system - including skilled and motivated providers engaged with the women and communities whom they serve. Assuring the quality of this system, the services and the care that women receive requires many inputs, including effective and efficient monitoring mechanisms. The purpose of this article is to summarise the practical steps involved in applying one such mechanism, criterion-based clinical audit (CBCA), and to highlight recent lessons from its application in developing countries. Like all audit tools, the ultimate worth of CBCA relates to the action it stimulates in the health system and among providers.
Confidential Inquiries into Maternal Deaths: Modifications and Adaptations in Ghana and Indonesia - Hussein, J., D'Ambruoso, L., Armar-Klemesu, M., Achadi, E., Arhinful, D., Izati, Y., Ansong-Tornui, J
This study introduced practical ways to encourage the implementation of maternal death reviews, inquiries, and audits that are context specific and, therefore, acceptable to local practitioners.
In June 2012, the Accountability and Monitoring in Health Initiative (AMHI) of the Open Society Foundations’ (OSF) Public Health Program convened a capacity building consultation to inform our strategy that included 25 people from 16 organizations bringing experience from Southeastern Europe, Central America, South Asia and East and Southern Africa. Attendees included experienced practitioners in the field, organizations supported by AMHI and OSF colleagues interested in these approaches. The consultation produced a full report and short paper that address many critical questions in capacity building, including, but not limited to, the underlying values, an analysis of different methods used and perspectives on assessing progress. Given the wide base of contributors and the potential relevance to others’ capacity building work, AMHI is pleased to share these materials through the COPASAH website. Download full report Download short paper
Promoting participation through community development projects and local decentralization has become a central tenet of development policy. The World Bank alone has invested about $85 billion over the last decade on development assistance for participation. However, some observers feel that policy making in the area is conceptually weak, that project design is informed more by slogans than careful analysis. There have also been questions about whether participatory development is effective in reducing poverty, improving service delivery, and building the capacity for collective action. Some observers also find that participatory projects are complex to implement and deeply affected by context, and are thus unsuited for large development institutions such as the World Bank. This groundbreaking report carefully examines each of these concerns. It outlines a conceptual framework for participation that is centered on the concept of civil society failure and how it interacts with market and government failures. The authors use this framework to understand the key policy debates surrounding participatory development and to frame the key policy questions. The report conducts the most comprehensive review of the evidence on the impact of participatory projects to date, looking at more than 400 papers and books. The report argues that participatory development is most effective when it works within a 'sandwich' formed by support from an effective central state and bottom-up civic action. This report represents an important contribution. It has significant implications for how to improve participation in development interventions and for development policy more broadly.
Action and Knowledge draws on twenty years of experience with the techniques and philosophy of PAR using case studies from Asia, Africa, Latin America and North America to show how widespread this approach to development has become since it emerged as a new way to empower the oppressed two decades ago.
The pack consists of: an Overview Report outlining the main arguments and approaches in regard to citizenship, gender and development; a Supporting Resources Collection providing summaries of case studies, tools, manuals and contacts; a Gender and Development In Brief newsletter made up of three short articles on the theme.
An indispensable resource for health educators, this book shows – with hundreds of methods, aids and learning strategies – how to make health education engaging and effective, and how to encourage community involvement through participatory education.