Literature Review: Civil Society Engagement to Strengthen National Health Systems to End Preventable Child and Maternal Death

David Shanklin, MCSProgram/CORE Group

CORE Group Global Health Practitioner Conference Portland, OR

Friday, May 20, 2016

Study Rationale

• The role of civil society in national health system strengthening remains ill-defined.

• Disagreements continue to exist concerning the roles and responsibilities of donors, governments and civil society itself.

• The authors intended to identify the potential of civil society engagement to strengthen national health systems.

“Real development requires more than assistance and aid. One of the things we’ve learned is you can’t skip the governance component, and that’s been a painful

and important lesson.” Chris Beyrer, MD, MPH, JHU, BSPH

Secretary of State Clinton (2011) described legitimate “country ownership”:

“To us, country ownership in health is the end state where a nation’s efforts are led, implemented, and eventually paid for by its government, communities, civil society, and private sector…and those plans must be carried out primarily by the country’s own institutions, and then these groups must be able to hold each other accountable…”

Methodology

• Iterative on-line search for public health articles between the years of 2005 and 2015.

• More than 160 articles were identified. • Articles reviewed based on relevance to this

search, and classified into four categories: evidence (49), guidance (30), information (28), and advocacy (1).

• In all, we referenced 108 articles for this review.

Key Definitions

Civil Society is a wide array of formal and informal associations and organizations that advance public interests and ideas and are independent of the public and for-profit private sectors. This definition differentiates civil society from the for-profit private sector. However, the private sector may include both civil society organizations and for-profit service providers.

Organization of Literature Review

Results are organized into three recurring themes:

1. Roles of civil society and civil society organizations

2. Key elements of successful civil society engagement

3. Reported benefits of civil society engagement

Roles of civil society and civil society organizations

There are eight basic roles of civil society related to national health care systems:

1. Public information, advocacy and policy development 2. Public oversight 3. Participatory governance 4. Direct service provision

Roles of civil society and civil society organizations (Cont’d)

5. Capacity development

6. Resource mobilization

7. Research and innovation

8. Networking

Participatory Governance

• Also described as “social accountability” • Many examples of tools and methods available

for: preparation and planning, involving marginalized populations, identifying barriers to participation, engaging civil society partners with the government/public sector

• Public accountability and transparency, and measuring outcomes

Key elements of successful civil society engagement

Three domains of a framework for civil society engagement in national health programming:

1. The national context, or the “enabling environment”

2. Partner capacity, with a shared common understanding of roles and responsibilities

3. Clear health need and available resources

USAID’s CSO Sustainability Index

• Highlights advances and setbacks in CSO sector sustainability

• Allows for comparisons across countries and sub-regions over time in 7 key components: legal environment, organizational capacity, financial viability, advocacy, service provision, infrastructure, and public image

USAID’s CSO Sustainability Index (Cont’d)

• 2013 CSO Sustainability Index for sub-Saharan Africa evaluated the CSO sector in 25 countries

• 10 of the 25 countries were in the Sustainability Impeded category, the weakest level.

• The other 15 countries remained in Sustainability Evolving, the middle range of CSO sustainability.

USAID’s CSO Sustainability Index (Cont’d)

• No country transitioned between 2012 and 2013, and no country reached Sustainability Enhanced, the strongest level of CSO sustainability, in any dimension.

Reported benefits of civil society engagement

Five reported benefits of civil society engagement that parallel the roles of CSOs in national health systems: 1. Increased public awareness of unmet health priorities and the importance of health service quality 2. Increased funding for high priority public health topics

Reported benefits of civil society engagement (Cont’d)

3. Participatory governance introduced, supported and capacity developed 4. Demand and use of health care increased and improvements made to service quality 5. Health outcomes improved, including increased service equity among marginalized populations

Increased public awareness

• Heightened awareness of unmet health needs • Importance of service quality to positive

outcomes • Some evidence of shortfalls in CSO capacity

to monitor results, and contribute to longer-term development outcomes

Increased funding for high priorities

• Strong evidence from HIV/AIDS: Civil society engagement predated global funding

• CSOs engaged early in: HIV/AIDS de-stigmatization, promoted prevention (such as condom use and other messaging), and energetically promoted increased funding

• Other examples: National advocacy for directing financial resources to specific priorities, such as maternal care; local mobilization of resources for CB services

Participatory governance

• National/local CSO participation in health planning and budgeting

• Use of checklists to monitor policy implementation

• Improved transparency and monitoring • Open and available data, and mechanisms for

regular discussion on findings

Participatory governance (Cont’d)

• Identify barriers to accessing services, such as physical, economic, cultural, familial, and transportation

• Organize priorities, develop and measure indicators, and make suggestions for improvements

• Frequently identified CSO capacity needs: governance skills, measurement (M&E), advocacy, and resource mobilization

Improved demand for quality health care

CSOs increase service demand and improvements in health services in 3 ways: 1. Play a role in shared monitoring and oversight

2. Provide services directly in conjunction with a national health system

3. Inform communities of improvements, and mobilize public to seek timely health services

Improved program outcomes

• Increased public awareness regarding treatment for common illnesses and diseases

• Increased timely use of services • Decreased incidence and mortality • Increased equity, serving hard-to-reach, at-risk,

and marginalized populations • Greater involvement seems to improve

resource sustainability and infrastructure quality

Limits of civil society effects

• More often achieved in an enabling context • Not a replacement for weak national plans • Community engagement has little impact on

outcomes when done in isolation • Community engagement can substantially

amplify the impact of investments in public health inputs

Conclusions

1. Community engagement leads to significantly larger reductions in maternal and child mortality, larger improvements in health-related behaviors and greater use of health facilities than investments in health inputs alone can deliver. 2. Successful programs are often located within larger government health delivery systems.

Conclusions (Cont’d) 3. Evidence suggests that the most successful programs tend to be implemented with sub-national governments that have some management autonomy and are downwardly accountable.

4. When civil society is engaged in multiple ways, in the context of a safe and enabling environment (even if nascent), the evidence is strong for positive health impacts.

For more information, please visit www.mcsprogram.org

This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the authors and do not

necessarily reflect the views of USAID or the United States Government.

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Proposed model for civil society engagement

Provides basis for MCSP program design in selected countries and for concurrently developed MCSP CSE Strategy.

Advances three outcomes:

1. Improve population health, demand and outcomes, including lowered maternal, newborn and child mortality rates, with increased health equity.

Proposed model for civil society engagement (Cont’d)

2. Develop and support social accountability processes to inform both local and national processes.

3. Build country ownership for health with shared accountability through improved governance of health involving government, civil society, and the private sector.

Next Steps within MCSP/CORE Group

• Develop guide to current social accountability tools and materials for adaptation in country settings

• Promote the active engagement of government and civil society through forums to jointly address unmet RMNCH issues

• Malawi and Ethiopia appear to be prime candidates for these applications

Key Definitions (Cont’d)

Social Capital is the connections among individuals in social networks, and the norms of reciprocity and trustworthiness that result from them. It is the degree and quality of these networks, norms and trustworthiness that bond similar individuals together or bridge diverse people together.