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Engaging Marginalized Communities in the Process of Accountability in Health: Challenges and lessons learned

GPSA Knowledge Platform forums Discussions with Experts Engaging Marginalized Communities in the Process of Accountability in Health: Challenges and lessons learned

This topic contains 12 replies, has 9 voices, and was last updated by Profile photo of Judith Judith 2 years, 6 months ago.

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  • #2806
    Profile photo of Walter Flores
    Walter Flores
    @walterflores

    In many countries, socially excluded populations (due to ethnicity, race, gender, age, poverty, etc.) experience many barriers to access public services-including health care services.  This occurs despite national and international legal frameworks that preclude discrimination and require the protection of vulnerable populations.  Based on a human rights based approach, civil society organizations in different countries-members of COPASAH- have been developing processes and tools to engage marginalized communities in social accountability.   This forum will share the challenges and lessons learned around three key issues:

    1) In social accountability work, the engagement between users and service providers is often taken for granted.  When working with marginalized communities, the first major challenge is to facilitate the linking of communities that do not trust public services/government agencies and public workers that may not be interested in assisting groups that suffer social stigma.  What are the specific barriers? What strategies have been effective to facilitate this engagement?

    2) Attempting to tackle marginalization inevitable means confronting oppressive and exploitative power relations.  Conflict is therefore an inherent situation and it is expressed at different levels-from the frontline of health care delivery to national policy and decision-making. The challenge here is to transit from   conflictive to a collaborative relation among different actors to tackle structural discrimination.  What strategies and tactics have been implemented? What have worked?

    3) Social accountability can be an entry door for health care workers and communities working together to bring changes from the bottom.  These changes will require social mobilization and political actions to connect with other reforms processes at provincial and national level.  What strategies and tactics are being implemented? What seems to be working?

    If you are interested in learning, discussing and sharing around the above, please do participate in the forum.

  • #2815
    Profile photo of Gina I.
    Gina I.
    @gina-chacon
    Mexico

    Participants,
    Welcome to the expert forum! To have a broader information about the discussion and ideas mentioned by our guest expert, we invite you to listen the video of the webinar ENGAGING MARGINALISED COMMUNITIES IN THE PROCESS OF ACCOUNTABILITY IN HEALTH – COPASAH PERSPECTIVES AND EXPERIENCES presented by Edward Premdas Pinto, Director of Research and Advocacy, Centre for Health and Social Justice, Delhi, India, and COPASAH South Asia Coordinator. http://gpsaknowledge.org/events/gpsa-webinarengaging-marginalised-communities-in-the-process-of-accountability-in-health-copasah-perspectives-and-experiences/#.VG4on_mG-So

    We look forward to read your contributions!

    • #2857
      Profile photo of Sandra
      Sandra
      @sandraarthur
      Ghana

      A lesson learnt from the presentation was that one should not rely solely on tools. The community should be muvh involved in yhr design of Social Accountability strategies

  • #2861
    Profile photo of Walter Flores
    Walter Flores
    @walterflores

    Thanks, Sandra, for your input. Indeed, social accountability, as understood by many of us within COPASAH, is not a set of tools but a a process that involves different strategies and tactics to overcome the barriers and causes of marginalization and connecting socially excluded populations with public services and overall state apparatus. We do use tools-and many of the tools are similar to those used by other organizations-but the main difference is that the interventions are not guided by the tools.

    With the aim of generating an exchange of ideas and experiences, I am including here, a link to a table that I have developed that attempts to summarize what I consider the three main approaches to social accountability that we have nowadays. In my table, I have 5 categories/characteristics that are relevant to understand approaches to social accountability: a) what is the main idea? b) what are the aims of implementing accountability interventions c) what framework supports this approach d) how the approach addresses power relations and e) who is to be hold accountable?

    Corporate responsibility is the approach that is being followed by many organization that are presenting themselves as “socially accountable” organizations. Although some of these organization may be in the development field, many others are not directly involved and in my view, they are basically using concept and ideas that are “trendy”. The heart of the comparison in my table is between the “consumers” and “human rights” approach. My observation is that many interventions that are based on the “short route to accountability framework” fall within the consumers approach. For those organization applying a human rights approach, although there is a lot of diversity in the specific processes implemented (due to context, expertise, and available resources) they have in common an understanding that public policies and services are failing not only because of lack of technical capacities and funding but mainly because structural determinants that cause “inequities of power”.

    To all forum participants: I would like to read your opinions in relation to my above inputs and my summary table comparing the three approaches. Do you agree or disagree? Have you observed different or additional things to the ones I have described?

    • This reply was modified 2 years, 11 months ago by Profile photo of Walter Flores Walter Flores.
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    • #2865
      Profile photo of Walter Flores
      Walter Flores
      @walterflores

      I forgot to add to my above entry that within the medical education field, there is a movement towards “socially accountable ” medical education. Within this movement, it is notably to mention TheNet, which is a network of medical schools with a history of engaging with the communities they serve and an explicit concern for health equity (http://thenetcommunity.org) Although their interventions present a lot of corporate responsibility characteristics, they also present some characteristics of human rights based approaches (see TheNet evaluation framework). I think there is an enormous potential benefit if medical schools-and all schools training health workforce-were to connect their students with the reality and struggles faced by the communities they serve and if both-users and providers of services- were to work together to change the conditions that cause both ill health and low performance of public services.

  • #2868
    Profile photo of Caroline
    Caroline
    @cgibu
    Peru

    Hello members of the community,

    Walter, thank you very much for your contributions. I find very interesting your point of view concerning of the implementation of social accountability in health services.

    I also find very interesting your analysis of consumer theory, social responsibility and human rights. However, I would add an additional item for discussion: i) the health and education services are public goods, can be administered by State or by a private entity, but is a function of the State to ensure access especially vulnerable populations; ii) the consumer of a public good should have quality service, even if you can not pay for it; and in the same manner iii) the consumer of a public good should have channels of complaint and suggestion that allow to solve conflicts and improve service.

    In addition, social organizations can support improved public services empowering its users, but also generating competition for better services to the citizen: the rankings and awards can contribute. In Citizens Day, the organization I represent, we tested these incentives over the past 12 years.

  • #2883
    Profile photo of Walter Flores
    Walter Flores
    @walterflores

    Hi Caroline,
    Thanks for your inputs. I agree with you statement that although services may be provided by a private entity, it is is still a function of the State, However, I would add that instead of a “function”, it is State´s responsibility. The experience is that unless the State is the ultimate responsible, then marginalized populations very easily fall through the cracks.

    In terms of competition for better services, I am not sure if competition works or whether it is a good mechanisms for services that are aimed to marginalized populations. In the several countries that I have worked in, I am yet to see social organizations competing to provide services to these populations. If there is competition, it is around the provision of services for middle income users. Do you happen to know examples of competition among providers resulting in better services for marginalized populations? Maybe the results of your own organization that you mentioned.

  • #2907
    Profile photo of Dr G K
    Dr G K
    @gyanesh007
    India

    Dear Members

    Social Accountability implies the engagement of marginalized communities to express demand for public services, and exact accountability from local service providers to improve healthservice quality. Social accountability is being increasingly recognized by state and non‐state institutions as a means of enhancing democratic governance and improving healthservice delivery. It refers to a broad range of actions and mechanisms that citizens, communities, independent media and civil society organizations use to hold public officials and public servants accountable.
    However, critical to the success of Social Accountability initiatives is civil society and state capacities, and the synergy between the two. Ultimately, the effectiveness and sustainability of social accountability mechanisms is improved when they are “institutionalized”. This involves two things: first, the state as a ‘willing accomplice’ in the broader accountability project, needs to render its own “internal” mechanisms in a way that makes it structurally amenable to accountability, and second, the state needs to identify and adopt mechanisms to facilitate and strengthen civic engagement and citizen voice

    • This reply was modified 2 years, 10 months ago by Profile photo of Dr G K Dr G K.
  • #2973
    Profile photo of Gladys
    Gladys
    @gladysnantume
    Uganda

    Thank you Premdas and Walter, for your enriching information about engaging marginalized communities in the process of accountability in health.
    Using the community based monitoring intervention has been seen as a prospective way to engaging communities in social accountability. This being a participatory process, communities where CIDI has employed the intervention not only in health but also in WASH have had many of the challenges addressed by the respective duty bearers through bringing them on board in organized dialogues for the community to voice out.
    It should also be noted that communities have been greatly encouraged to work hand in hand with community based organizations (CBOs) and also established structures within the communities themselves. These are what we have referred to as community advocacy structures/ groups comprised of members democratically elected by the community.
    On the overall, the project has a set of activities that aim at seeing the community and its representatives understand the accessibility, quality and effectiveness of health services that the community is entitled to.

  • #2987
    Profile photo of Saad
    Saad
    @saad
    Morocco - USA

    Dear Social Accountability practitioners and experts,
    Espace Associatif – EA (www.espace-associatif.ma) in Morocco is developing a project on Social Accountability in the health sector. The entry point to this experience is the importance of the right to health and the monitoring of economic and social rights in the strategy of EA. The project was launched in March of 2014, with the support of the Human Rights Initiative of Open Society Foundations, and has developed an assessment of levels of access to information for citizens and communities, professionals and associations in the health system in rural and urban areas of the Rabat region, in the center of Morocco. This is quite an optimistic approach, given that Morocco does not count with a FOI law yet, and only the constitution provides for the right to access information in its article 27. The information about data analysis and research on health is very limited in general, especially those developed by CSOs.

    Social Accountability is relatively a new concept in Morocco, and the number of CSOs developing SA experiences is very limited. The majority of existing experiences are relatively embryonic. To prepare the ground for SA mechanisms to be developed with local communities and CSOs, EA conducted during this pilot phase of the project surveys with different stakeholders to analyze the typology of information that exists, and assess its level of accessibility and for which stakeholders. This experience aims to compare levels of access, quality of services provided, level of knowledge of existing services among users and especially the marginalized ones who are supposed to benefit from the RAMED system (system for marginalized groups launched by the Government of Morocco in 2013.

    The involvement of the government and its agencies during this first phase of the project has been very limited. Its participation was reduced to providing some internal research and documents to support the research and analysis work. The project has developed a very important research and data analysis based on the surveys conducted, and developed specific conclusions and recommendations to share with different stakeholders. The next phase will consist in addressing in collaboration with government agencies the significant challenges identified in the health system during the first phase. Thus, by training local stakeholders and assisting them in developing local SA projects and specific actions to address local health issues. All these actions in different regions of Morocco will feed the advocacy processes on improving access and quality of the health services and the realization of the right to health. This will be conducted at the national level by EA.

    More information and details about the project can be found here: http://www.espace-associatif.ma/Systeme-de-sante-efficace-pour?lang=fr

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  • #3024
    Profile photo of Walter Flores
    Walter Flores
    @walterflores

    Dear all,
    Thanks for your contribution during the forum. If you are interested in continuing the exchange and learning about promoting social accountability within marginalized populations, I suggest you follow and participate in the exchange within the COPASAH (www.copasah.net)
    Regards
    Walter

  • #3671
    Profile photo of Steven
    Steven
    @stetsonman
    Malta

    Hi Walter,
    While I cannot in all fairness call myself a social accountability practitioner, I am a Social Impact Assessment (SIA) practitioner on urban development projects in a developed country context. On the other hand, I am a committee member of an NGO that supports families and adults with ADHD, and we have been trying to influence both policymakers on the one hand to be more inclusive and holistic towards how they tackle the problem of ADHD in Malta (an EU member state since 2004) and for the people we represent to be more active and have a proper space where they can voice their problems and what needs to be changed to improve their well-being and that of their families.

    We have found it very difficult on both fronts. First, ADHD is not something that touches the health care, but it is a holistic problem that is transversal – it is affected by multiple policies and legislations across a number of ministries and their portfolio. The fact that each ministry has its own budget and remit means that the problems that we are tackling cannot be solved by one entity within Government, but needs to be tackled by a number of key ministries, some of which do not necessarily have a healthy communicative apparatus or history of knowledge transfer and collaboration. Over the past year we have been approaching key officials in key ministries to share our concerns, increase awareness and advocate for a cross-ministerial forum for discussion. We have now a number of Ministers on board but we still have to organise the forum in such a way that it actually yields results, namely a change in policy, a long term strategy and the implementation of both policies and strategies. The fact that ADHD is 1) an “invisible” condition or disability, depending on how you look at it and 2) that it is mainly perceived as JUST an educational problem, are two of the most important stepbacks that we have, because some decision-makers fail to see the connections between education, health, well-being and criminality, for example.

    ON the other side of the coin, we have problems mobilising our members to be more vociferous about their needs and to hold the Government accountable. We need to find strategies that doesn’t just create the space for engagement but mobilise such engagement in a way that is fruitful. I think that one of the biggest problems is, as with many who work in this sector, that the reality of the problems on the ground for those affected are immediate and they are not in a position to wait for change at an institutional level to take place. Their children are being psychologically abused at school, many are single parents with problems at home, some cannot hold jobs either because they themselves suffer from ADHD or they have to spend a lot of time taking care of their children so that they do not get either kicked out of school or for older children, end up having problems with the law, etc. In fact, even though we have been working very hard to tackle even single cases, we find virtual walls wherever we turn. This does not mean that we have not had successes, but the problems seem to outweigh the successes we have had.

    I would be very grateful if I could get some pointers on how to tackle these problems and for the NGO that I am part of to be more effective, both in our short-term goals as well as the longer term ones.

    Thank you and I look forward to your reply and those of the practitioners of this forum.

    Steven

  • #3759
    Profile photo of Judith
    Judith
    @judithstemerdink-herret
    Austria

    Today I talked to a colleague in the development aid sector in the Northern arid lands of Kenya. We discussed the prevailing issue of FGM (Female Genital Mutilation or Cutting) among pastoralist communities. The Kenyan Government enacted the law on “Prohibition of FGM Act” in 2011. Yet the implementation in the rural areas is not seen.

    The question for me starts before the social accountability of the health services and the awareness raising from the County Government or CSOs: FGM is an old tradition with cultural and religious value specifically still among the pastoralists. These marginalised communities have not been consulted if the Prohibition of FGB is contradictory to their public values or not. According to the CSOs working with the local communities FGM is still accepted but now practiced secretly with even worse health impact on the young women. The communities have the impression that Gov imposed something against their will (even when here with good intention and globally condemned). Further the communities do not trust the Gov and its health services because they know FGM is forbidden.

    How to break this cycle of feeling marginalised and not heard from the communities and at the same time do awareness raising on the health impact of FGM?
    Is social accountability among health care workers and communities on other topics that are urgent & important to the communities an entry point to build again trust?

    Looking forward to some inspiring thoughts!

    Best wishes, Judith

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