Participating voices: Constructing Programmatic Change for Inclusive Policies

1
Participating voices Constructing Programmatic
Change for Inclusive Policies

• Ariel Frisancho Arroyo
• Improving the Health of the Poor a Human
  Rights Approach
• Program Manager
• (CARE Peru)
• afrisancho_at_care.org.pe

The Demand for Good Governance Summit June 2,
2008 World Bank / Washington, D.C.
2
General Information

• Program purpose to strengthen Peruvian state /
  society relations in the health sector, promoting
  poor peoples health rights
• Expected outputs a) Civil society organisations
  develop and strengthen strategies for making
  health sector policies and institutions respond
  to, protect and promote health rights, especially
  of the poor and marginalized people b) Civil
  society and health providers have developed
  participatory and inclusive mechanisms for
  planning, provision and evaluation of health
  services
• 2004 DFID / 2005-2008 DFID, through PPA w/CARE
  UK

3
CAREs Health Rights Program World Banks
Accountability Triangle
NATIONAL GOVERNMENT Responsible for Policy
Making
Prioritization of Social Expenditure, Management
Agreements, Standards for Health Services Payment
Demands to congressmen, Claims through coalitions
as ForoSalud, Regional Health Councils
Politicians, congressmen
MoHealth, MoEconomics, MoLabour
Health Services Users Rights Law
Ministry of Health
Decentralisation Devolution, delegation
ForoSalud (Main Civil Society Health Network)
Health Policies Capacity Building on Health
Rights Participation
SUB-NATIONAL GOVERNMENTS

• Social Surveillance
• gt Voice
• gtParticipation
• National
• Regional
• Provincial

Public Insurance
Ombuds-person Office
POLITICAL VOICE
Contract / Agreement
Participatory Monitoring
Alliances Civil Society
LOCAL GOVERNMENT
COALITIONS CITIZENS
PROVIDERS
USERS EMPOWERMENT
Physicians other Health providers
Hospitals, Health facilities and private clinics
Control of CLAS Assembly Participation in
Health Local Plans Participatory Budget, Choice
on Provider
Non-poor Health Services Users
Poor Health Services users
Participatory planning monitoring of CLAS
Citizen Surveillance Mechanisms Women
Empowerment
Improving
4

• Is it possible for citizens and civil society
  organizations to propel participatory strategies
  for making public policies and officers/
  authorities to contribute with the realization of
  health rights?

5
Strengthening CS Influence on Health Policies

• HR Program linked up with ForoSalud, the most
  extended nation-wide civil society network in
  health, to build capacity to participate in
  decisions about health
• Training on health rights and developing
  capacities for collective action and advocacy
  brought peoples bottom-up constructed policy
  proposals to regional / national policy dialogues
• ForoSalud members elected as people
  representatives in National Health Council / 10
  Regional Health Councils some ForoSalud policy
  proposals institutionalized (i.e. Mental Health,
  Health Promotion, etc)
• ForoSalud is now positioned as a key actor within
  Peruvian health sector, demanding consultative
  processes for social and health policy design, M
  Evaluation
• ForoSalud has advanced in its own democratization
  and decentralization process, and is currently
  building increasing representation of the most
  poor and excluded in its own structures.
• The recently appointed Peruvian Minister of
  Health (December 2007) has publicly recognized
  ForoSalud as a both political and technical key
  actor within Peruvian health sector.

6
ForoSalud Influence on Health Policies Outputs

• 2002 3 w/ women organizations defense on SRH
  priority
• Along 2004 Bottom-up processes to construct
  health policy proposals analyzing 1) Traditional
  health problems 2) key social determinants of
  health and 3) challenges on responsiveness of
  health system to people needs. Approach
  incorporated nation-wide in 2006 by MoH.
• 2005 -6 Nation-wide campaign raising awareness
  on challenges USA - Peru Free Trade
  Agreement could generate for access to
  medicines/now taken into account for FTA
  implementation.
• 2007 w/ women leaders citizen surveillance
  scheme in Puno turned inspirational to the
  Minister of Health he has propelled MoH
  surveillance committees for the national
  hospitals
• 2008 ForoSalud representatives in the National
  Health Council successfully obtained the Minister
  of Health support and the National Health Council
  approval of a Law proposal to balance composition
  of "invited spaces", including the realization of
  National Health Conventions, with a bottom-up
  approach for the participatory presentation and
  discussion of the new government health policy
  and commitments.

7

• ForoSalud CARE Peru multi-level
• Accountability Approach
• International
• Shadow report civil society follow-up on Paul
  Hunt (UN Special Rapporteur on Health Rights)
  Recommendations to Peru
• National
• Law proposal on Health Services users Rights
  Responsibilities
• Balancing power-relations within invited spaces
  for policy dialogue negotiation
• Regional Local
• with ForoSalud, PHR USA Ombudsperson
  Regional Office
• Citizen surveillance on health services and
  social programs quality effectiveness in Piura
  Puno regions, linking Quechua and Aymara women
  community leaders to regional offices of the
  Ombudsperson to monitor womens health rights,
  particularly their right to good quality,
  appropriate maternal health services

8
Lessons learned

• Participation as a means for influencing public
  health policies and as an end in itself for
  empowerment building of citizenship
• Social communication dissemination of health
  rights
• Support the social movement agenda, with no
  intention on imposing the aid agency agenda
  (trust the locals)
• Strengthening Voice is not enough to strengthen
  governance work with both the demand and supply
  sides
• Multi-level interventions addressing a)
  capacities of both right-holders and duty
  bearers, b) strengthening dialogue spaces and c)
  broader policy environment, through social
  communication strategies to raise awareness
  amongst public opinion. On the other hand,
  Development Aid could be very influential
  promoting rights better governance

9
Model for Governance Rights Engagement
Layer 4 The international community might become
very influential in promoting rights,
participation and government fulfillment of its
obligations Or, it might not.
Key assumption - strengthening Voice is not
necessarily enough to strengthen
governance. (Based on a graphic of Goulden, J.,
adapted by Frisancho, A. Please send comments
and inquiries to afrisancho_at_care.org.pe)
10
Strengthening MoH Ownership of RBA

• Window of opportunity upcoming visit by the UN
  Special Rapporteur on the Right to Health and
  newly appointed Minister of Health (2004) allowed
  CARE to address institutional shortcomings in
  cooperation with MoH
• MoH improved relationships with civil society
  placed inclusion and cultural appropriateness as
  institutional priorities and created technical
  units to work health rights contents within MoH.
• 2004-06 National Mobilization on Health Rights
  implemented macro-regional workshops training
  on health rights and citizen participation
  sanctioned norms to include cultural preferences
  within health care practices.
• Participatory construction of CLAS Law (2005-08)

11
Chief challenges

• Social indifference facing the exclusion of the
  poor
• Facing weak legal enforceability mechanisms, need
  of strengthening responsiveness, engagement and
• accountability from public health services and
  MoH
• Historical top-down relations and power
  inequities between health providers and community
  (patrimonialismo)
• Promoting social rights involves risks
  authorities misunderstanding of CARE role, when
  contributing to address institutional
  shortcomings and systemic inequity
• Lack of personnel within the regional
  Ombudsperson offices, i.e., six officers for a
  whole region
• Engaging local experiences with major stake -
  holders from the start promoting ownership
  (early appropriation)

12
Lessons for Development Aid Agencies

• Accountability Triangle working with demand
  (long run, short run) as important as
  strengthening government development programs
• Advocacy processes demands capacity building
• Importance of strengthening the interface between
  community and state national decentralisation
  processes should give attention not only to the
  quantity of participation provided by new
  participatory mechanisms, but to its quality
  (representative-ness, voice brought to decision
  making tables, etc)
• Promoting governance and empowerment demands time
  and a more flexible approach which are more
  difficult to get incorporated within traditional
  co-operation deadlines and frameworks