Social Accountability: A Primer for Civil Society Organizations Working in Family Planning and Reproductive Health

Publication date: 2015

HEALTH POL ICY P R O J E C T Social Accountability a primer for civil society organizations working in family planning and reproductive health ISBN: 978-1-59560-112-4 The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID- OAA-A-10-00067, beginning September 30, 2010. HPP is implemented by Futures Group, in collaboration with Plan International USA, Avenir Health (formerly Futures Institute), Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA). The information provided in this document is not official U.S. Government information and does not necessarily represent the views or positions of the U.S. Agency for International Development. Suggested citation: McGinn, Erin, and Alyson Lipsky. 2015. Social Accountability: A Primer for Civil Society Organizations Working in Family Planning and Reproductive Health. Washington, DC: Futures Group, Health Policy Project. Social Accountability a primer for civil society organizations working in family planning and reproductive health by Erin McGinn and Alyson Lipsky September 2015 2 social accountability for FP/RH contents 3contents Acknowledgments 4 Abbreviations 6 1 Introduction 9 2 What is social accountability? 13 2.1 Why engage in social accountability for family planning 18 2.2 Getting involved in social accountability 20 2.3 Country context matters 24 2.4 Lessons learned from social accountability efforts 27 3 Mechanisms of social accountability 29 3.1 Citizen involvement in monitoring public services 30 3.2 Influencing and monitoring financing 36 3.3 Collaborative planning and/or management 45 4 Linking social accountability and legal action—the “enforceability” component of accountability 59 4.1 International and national legal rights to reproductive health, including family planning 60 4.2 Strategic litigation as an accountability mechanism 62 5 Organizational capacity to engage in social accountability 67 5.1 What human resources are needed? 68 5.2 What financial resources are needed? 71 6 Maximizing the impact of social accountability efforts 73 7 Social accountability—pivoting our FP programming 77 8 Resources 81 Endnotes and references 86 4 social accountability for FP/RH acknowledgments 5acknowledgments The authors greatly appreciate the valuable contributions of their Health Policy Project colleagues: Mariela Rodriguez (now with CARE) and Kay Wilson for their assistance with the literature review; Jay Gribble, Ann Hudock, Elizabeth Leahy Madsen, Jennifer Pendleton, and Taylor Williamson for their technical review; and Lori Merritt and Pol Klein for their editing and design of the document, respectively. We are particularly appreciative of several experts who contributed their own programmatic experiences and technical input for this publication: Ray Mitchell (White Ribbon Alliance), Laura Malajovich (International Planned Parenthood Federation/Western Hemisphere Region), Joanna Fine and Rebecca Brown (Center for Reproductive Rights), and Esperanza Delgado Herrera (Mexfam). 6 social accountability for FP/RH abbreviations 7abbreviations CEDAW Convention on the Elimination of all Forms of Discrimination Against Women CIP Costed Implementation Plan CRC citizen report card CSO civil society organization DFID U.K. Department for International Development DLGN Decentralization and Local Governance Network FP family planning FP2020 Family Planning 2020 HIV human immunodeficiency virus IDS Institute of Development Studies IHP+ International Health Partnership + IPPF-WHR International Planned Parenthood Federation-Western Hemisphere Region MOH Ministry of Health NGO nongovernmental organization OSAR Observatorios en Salud Reproductiva or Reproductive Health Observatory OSF Open Society Foundations PBF performance-based financing PETS Public Expenditure Tracking Survey QSDS Quantitative Service Delivery Survey RH reproductive health SRH sexual and reproductive health SRHR sexual and reproductive health and rights SWAp sector-wide approach TWG technical working group USAID U.S. Agency for International Development WHO World Health Organization WRA White Ribbon Alliance 8 social accountability for FP/RH 9introduction introduction 10 social accountability for FP/RH Reproductive rights are fundamental human rights, and the realization of these rights through access to family planning (FP) is linked to greater gender equality, improved health, women’s empowerment, and economic growth. The right to freely and responsibly decide if, when, and how many children to have has been enshrined in numerous international treaties, conventions, and political consensus documents.1 Most recently, more than 25 national governments gathered for the London Summit on Family Planning in July 2012 to reaffirm numerous policy, programmatic, and financial commitments to family planning.2 Although some commitments were more program-specific and carried new funding opportunities, the spirit behind the London Summit complemented the strong international consensus that emerged from the Cairo Programme of Action (1994) and since has been reiterated in multiple international fora—that individuals have the right to family planning, and governments (in partnership with donors and civil society) have the responsibility to increase the availability of information on and access to high-quality FP services. Governments are responsible for manifesting their international commitments to family planning and reproductive health and rights through their policies and funded programs at the national, state/province, and local levels. These policies and programs guide how citizens receive information and access services to realize their reproductive rights. Yet, the reality is that for most countries worldwide, from the least to the most developed, governments fail in many respects to operationalize these international commitments. Women and men, particularly young women and men, face numerous barriers to their access and use of high-quality FP information and services. As a result, unmet need for family planning is pervasive (20–30% in most developing countries), and an estimated 40 percent of all pregnancies worldwide are unplanned, with half of those ending in abortion.3 In the field of international development, there has been increased attention over the past decade on the role of accountability—both at the global and local levels—as a key element of enhanced development. Efforts to improve aid effectiveness point to the potential for greater accountability to root out corruption, reduce inefficiencies, enhance the distribution of resources, and ultimately, improve health services. This link between accountability, improved 11introduction SOURCE: IDS. 2006. Making Accountability Count. IDS Policy Briefing Issue 33, November 2006. Brighton, UK: IDS, p. 2. “Accountability shapes people’s ability to realize their rights.” health services, and aid effectiveness was emphasized in the World Bank’s 2004 World Development Report. Likewise, human rights advocates and pro-democracy movements point to improved accountability and institutional responsiveness as essential for people to realize their rights. While not guaranteed, stronger accountability mechanisms have the potential to empower marginalized groups. As a result, international aid transparency and accountability mechanisms are on the rise because of their potential to help countries achieve greater impact and improve the cost-effectiveness of development interventions. For instance, transparency and accountability were key themes emerging from the 2011 Busan Partnership for Effective Development Cooperation,4 which emphasized governments’ accountability to their citizens and specifically included civil society as key participants in mutual accountability mechanisms. In 2014, the World Bank adopted and started implementing a comprehensive framework for citizen engagement in policies and programs it supports.5 Efforts such as the Aid Transparency Initiative (Publish What You Fund campaign) and the Open Budget Initiative are contributing significantly to advances in financial transparency, which, in turn, can result in greater accountability. Furthermore, several international initiatives and collaborations are explicitly incorporating accountability into their monitoring operations. For instance, WHO has initiated a Commission on Information and Accountability for Women’s and Children’s Health,6 and the Reproductive Health Supplies Coalition and Family Planning 2020 (FP2020) have established working groups that also address accountability. 12 social accountability for FP/RH This booklet focuses on the country level, where various accountability mechanisms have been developed and implemented, ranging from citizen feedback on service delivery to the participation of civil society organizations (CSOs) in budget planning and monitoring processes. The booklet is designed for CSOs looking to initiate or expand activities aimed at holding government entities accountable for meeting their health-related national and international commitments. It is focused primarily on social accountability for family planning but may be useful for CSOs working in other health-related areas. This document provides: • An overview of the current concepts of social accountability • A synopsis of common methodologies and tools used by civil society to engage in social accountability • Ideas and examples on how social accountability can be used to advance family planning and reproductive health (FP/RH) within a country • Suggestions on what elements CSOs might consider when deciding to implement a particular methodology • A resource section and bibliography to provide additional resources on specific social accountability issues and useful tools for implementing social accountability activities 13what is social accountability what is social accountability? 14 social accountability for FP/RH A key characteristic of good governance is that governments serve in the best interest of their citizens; they make pledges and commitments from the international to the local level and meet them through effective legislation and policies. In representative governments, government units (ministries, departments, offices) have the obligation, and citizens have the right, to hold government accountable for achieving its commitments. Horizontal accountability occurs when government units ensure other units within the same government fulfill their commitments through institutional mechanisms of oversight. These can include internal audits and parliamentary hearings. Vertical accountability occurs when forces external to government, such as citizens, advocacy groups, and the media, work to ensure government units meet their obligations. Mechanisms for this type of accountability include elections, mass protests, publication of shadow reports, and investigative news reports, among others. Diagonal (also known as hybrid) accountability occurs when governments invite active and meaningful involvement of citizens/CSOs in horizontal accountability mechanisms. This could include participatory planning and budgeting, citizen testimony in public hearings/oversight committees, or community representation on health committees.7 Social accountability is the term used when citizens or CSOs engage in specific activities that hold their leaders accountable for performance and press for good governance through either vertical or diagonal accountability mechanisms. It is characterized primarily by citizens’ active involvement in government decision-making processes to ensure government fulfills its commitments and implements policies and programs accordingly. Those who engage in social accountability bring fundamental principles of good governance and democracy to life—that is, the premise that governments have an obligation to inform and explain and that they are answerable to their people for political promises, use of financial resources, and how they govern.8 Social accountability is fundamentally a rights-based approach; it is predicated on the right to information, right to voice, right to organize, and right to participate in governance functions.9 Paired with these citizen rights is the responsibility of citizens to understand and play a proactive role in exercising these rights.10 15what is social accountability CITIZENS AND CIVIL SOCIETY Much of the governance literature uses the general terms “citizens” and “state.” However, it is important to note that government, or “the state,” is not only responsible to its “citizens” but generally has obligations toward individuals living within its borders, regardless of legal status. This may include illegal immigrants, refugees, and legal residents that may not be formal “citizens.” As such, use of the term “citizen” in this publication is meant broadly. Likewise, the term state and government may be used interchangeably and could denote the government in power or simply government institutions (bureaucracies). 16 social accountability for FP/RH Social accountability centers on the flow and interactions between three components: information, civil society (citizen) action, and government (state) response. Most obviously, social accountability interventions use information to catalyze civil society action to result in an official government response. However, civil society mobilization and action can also lead to the generation or dissemination of relevant information. The government’s response to citizen action can lead to information being released to the public. However, “all information is not equal; all citizen action is not the same and all official responses cannot be seen as accountability enhancing.” SOURCE: Joshi, A. 2013. Context Matters: A Causal Chain Approach to Unpacking Social Accountability Interventions. Work in Progress Paper. Brighton, UK: Institute of Development Studies, p. 12. 17what is social accountability info state response citizen action accountability • Public information can lead directly to change • State response can take the form of information disclosure • Information can catalyze citizen action • Citizen action can generate information • Citizens action can trigger a state response • State responses can shape citizen action Adapted from Joshi, 2013, p. 11. 18 social accountability for FP/RH 2.1 Why engage in social accountability for family planning? Family planning advocates continue to advance sexual and reproductive health and rights (SRHR) in both international fora and at the country level, and often celebrate important wins. It may seem that full realization of SRHR is merely lacking more and better advocacy at all levels. However, there are several reasons why incorporating social accountability into FP program design and advocacy efforts may be a strategic next step. • We still have not achieved our FP goals. The Cairo Programme of Action, which emerged out of the 1994 International Conference on Population and Development, set out a new vision among 179 countries for sexual and reproductive health and rights, including family planning. However, despite multiple reaffirmations of global consensus and country commitments to FP/RH rights in various fora, the reality on the ground is that we are far from achieving this vision—where everyone has a right to information, high-quality services, and an enabling environment to help them meet their reproductive intentions. FP advocates everywhere must ask themselves: Are there additional approaches that can make the Cairo vision a reality for all? • Social accountability approaches provide additional opportunities to affect change. FP advocacy primarily aims to influence key decisionmakers to achieve changes at the policy and program levels, while social accountability efforts aim to mobilize and empower citizens to engage with their government and in governance processes. Applying a social accountability lens to our work allows FP advocates to explore more fully how and where fundamental change in SRHR actually happens.11 It invites FP advocates to complement top-down efforts to change policies, programs, and ultimately systems and society with bottom-up/grassroots efforts to alter power dynamics between state and civil society, and ultimately, between a woman and the forces that inhibit her ability to realize her reproductive rights. Since accountability work is highly embedded in power dynamics, the analysis required 19what is social accountability to engage in social accountability can assist FP advocates to better understand the health system and the “kind of change required to truly realize sexual and reproductive health and rights.”12 • There is increased interest in social accountability among the global FP community. Social accountability concepts and tools are increasingly being integrated into FP programming and thinking. For example, FP2020, the partnership responsible for advancing the FP agenda, includes social accountability themes in both the Performance Monitoring and Accountability Working Group and the Rights and Empowerment Working Group. Likewise, several donors—such as the U.S. Agency for International Development (USAID), U.K. Department for International Development (DFID), and Hewlett Foundation—have signaled their interest in linking traditional FP interventions with social accountability efforts.13 Family planning advocates have an opportunity to harness this international interest in incorporating social accountability into FP programming. • There are synergies between FP advocacy efforts and social accountability strategies. Although the term “social accountability” is relatively new to the international FP community, there are synergies between holistic FP program efforts and social accountability strategies. Historically, FP programs have engaged in many activities that could fall within the social accountability arena. For instance, a pillar of FP development efforts has been quality improvement as part of service delivery. Several approaches to assuring and monitoring the quality of FP services include community engagement and feedback,14 which exhibit some parallels with social accountability approaches that seek to monitor health services, as described in the next section. In addition, budget advocacy has been an increasing focus of many FP groups, spanning efforts to change policies, increase budget allocations, and monitor spending to promote stronger government accountability for financing FP programming. 20 social accountability for FP/RH • Social accountability can improve health services and outcomes. Some emerging evidence indicates that social accountability initiatives can have a direct impact on the quality of health services and improving health outcomes. A commonly cited study on the impact of social accountability describes how community-based monitoring of health services in Uganda led to increased use of services, reduced child mortality, and increased child weight.15 Although rigorous documentation and evaluation efforts need to catch up to the implementation of social accountability initiatives, particularly in family planning and reproductive health,16 broader research from the governance field shows that “social movements and social mobilization, in general, play a key role in building more responsive and accountable and pro-poor states.”17 Likewise, programmatic documentation (grey literature) and testimonials from those implementing social accountability activities themselves assert that social accountability interventions can have a tremendous impact on health service delivery. For example, after the international nongovernmental organization (NGO), CARE, implemented a community scorecard process in select districts in Tanzania, facility staff reported an increase of FP uptake;18 a subsequent analysis of Tanzania’s medicine stock-outs by a local NGO, Twaweza, also pointed to the community scorecard process as one approach to address such issues.19 Further, Mexfam and its partners’ budget tracking and advocacy in Mexico contributed to a US$7.8 million budget allocation in 2011 and US$15.6 million in 2012 earmarked by congress to implement the national adolescent sexual and reproductive health program.20 2.2 Getting involved in social accountability Family planning practitioners interested in social accountability will soon realize that the program elements and ultimate goals of governance programming are different. For example, whereas FP advocacy initiatives may build a broad base of support and/or foster coalitions to exert pressure on government to change specific policies or programs, social accountability mechanisms “need to emphasise building broad and democratic constituencies to support social change.”21 The difference between 21what is social accountability How is social accountability different from advocacy? • Social accountability and advocacy have different primary goals. Social accountability’s goal is to engage and empower citizens to hold government accountable, while advocacy’s goal is to achieve an “ask,” such as prioritizing family planning in district budgets. It may be that a successful advocacy strategy involves engaging citizens (i.e., to conduct a mass action campaign), but citizen empowerment may not be required. • Social accountability and advocacy have different strategies. Social accountability builds sustainable relationships between citizens and government, while advocacy can be more adversarial. • Social accountability and advocacy have different starting points. While advocacy starts with an “ask,” with success defined by whether that “ask” is achieved, social accountability starts with building citizen empowerment and voice. Solutions to problems often evolve from the engagement between citizens and government. these two aims may seem slight, but from the governance perspective, social accountability programs aim to improve public management and, in particular, deepen democracy—to strengthen the relationship between citizens and the government that serves them. As such, from the governance perspective, social accountability is a program goal in and of itself. While from the public health perspective, the value of social accountability efforts is their use to improve service delivery. In all likelihood, social accountability for family planning can serve both purposes. However, FP practitioners emerging from the public health sphere need to recognize that designing social accountability interventions, establishing outcomes, and determining impact may need to incorporate a rights-based, longer-term strategic and process-oriented approach;22 this means having a programmatic commitment to enhance governance and democracy and promote human rights and having the ability to incorporate governance outputs and outcomes as measurements of success. Below are key considerations when deciding whether and how to incorporate social accountability efforts within an FP program. 22 social accountability for FP/RH what needs to be changed? what opportunities exist to engage government? what is the socio-political context? what are the organizational capacities and resources required? who is accountable? how can we achieve change? 23what is social accountability • What are the problems/conditions you are trying to change? When it comes to family planning and reproductive health and rights, the problems can be numerous: a local health post or clinic may only have one or two methods in stock at any given time; the provider may only be available on certain days; and clients might have to travel far to obtain clinical methods such as an intrauterine device or sterilization. The provider may not be courteous or respect confidentiality, and this might deter clients from seeking FP services at the clinic, particularly young people. Perhaps the services are too expensive, or “free” FP services are accompanied by informal fees. More broadly, women may be contending with social and/or spousal pressure related to their fertility choices, or communities may be experiencing high rates of adolescent pregnancies and/or high rates of maternal mortality and morbidity. Many factors could be contributing to these scenarios, but the first step is to decide how the current situation deviates from what is needed to ensure reproductive health and rights. • Are there existing government policies or plans to address the problem? In many cases, government, usually with input from civil society, has already laid out policies and strategies to ensure comprehensive family planning and reproductive health programming. Existing policies and strategies provide a useful benchmark against which citizens can hold government accountable. If existing policies lay out certain government commitments or actions, yet funding and/or programming has not followed suit, civil society can use these government documents to call attention to ways in which the government is not fulfilling its commitments. • Who is responsible? Social accountability involves citizens applying pressure, aimed at or in partnership with government, to ensure the government fulfills its obligations to all citizens. So in the scenarios described above, it is important to understand who is responsible for change, or in many cases, what government unit and at what level. For instance, the Ministry of Health (MOH) may issue national policies 24 social accountability for FP/RH or guidelines, but their implementation may rely on local government staff (such as a district medical officer or someone responsible for community development). When it comes to budgets, in many countries, they are negotiated both at the national level (between the Ministry of Finance and MOH, with the executive and legislative branches) and at the local level (state/county and district/municipal/local budgets). Poor service quality may be a result of poor clinic management and attributable to individual providers, but it is often influenced by larger health systems issues. Identifying who has a role in making change happen will help decide how best to hold them accountable. • What are the most strategic social accountability approaches? Civil society can use myriad mechanisms and tools to hold government accountable for the provision of FP/RH information and services. Organizations deciding which approaches to use should consider the nature of the issue, who is accountable, the overall social and political culture and context of the country (political economy analysis),23 the existing opportunities and structures for interacting with government, and their own internal capacity to engage in social accountability (see Section 5). Section 3 details the various mechanisms of social accountability. 2.3 Country context matters Various hindering and enabling factors influence the outcomes of social accountability mechanisms on both the national and subnational stages. Countries with strong democratic processes, such as open elections, an independent judiciary, freedom of the press, and strong social movements with opportunities to express dissent can provide fertile ground for social accountability.24 The existence of regulations and protections for civil society—such as Right to Information legislation, rights of assembly, and a clear regulatory system outlining registration and tax status of CSOs25—demonstrate that government recognizes civil society’s rights to engage in governance. 25what is social accountability Governments with a history of oppression may have relationships with NGOs that can be characterized as “repressive,” “rivalrous,” or “competitive” and may not create space for civil society to flourish.26 In repressive countries, government may actively limit civil society.27 In countries where civil society has historically acted as an agitator against an oppressive government, both CSOs and government may struggle with more collaborative engagement, particularly when the government may not believe that civil society has the right to be involved in policy dialogue.28 Accountability initiatives at the local level may face different challenges than at the national level. For example, a free and fair media may exist conceptually and legally within a country, but in reality, local media houses (newspaper, television, radio) may be aligned with specific political interests.29 Family planning and reproductive health and rights can be a particularly challenging area to mobilize for social accountability. Family planning has historically (and unfairly) been seen as a woman’s issue or responsibility, and by far, most decisionmakers are men, making it challenging to garner their attention for reproductive rights compared to other health issues (e.g., malaria). This may be compounded in countries where conservative religious institutions align with conservative governments to undermine or even threaten political and social efforts to enforce women’s rights. In a difficult country context, social accountability efforts may be fostered by: • Cultivating FP champions among male policymakers and religious leaders by building the capacity of key individuals to speak publicly about family planning and educate others about the broad positive impacts that family planning has across health and other sectors. • Working to change perceptions and attitudes of government counterparts so they see CSOs as partners. For instance, CSO monitoring of health services can generate useful data and analysis for governments to better inform their program planning. 26 social accountability for FP/RH Likewise, CSO engagement in budget tracking can also strengthen the capacity of government counterparts to understand the budget development and expenditure process.30 • Finding issues that both civil society and government can support, because they can lead to more success than adversarial issues and build the relationship between civil society and government. • Leveraging international assistance. There is increasing international support for social accountability. For example, DFID directs each country office that provides budget support to spend up to 5 percent of its budget on strengthening domestic accountability through activities such as social accountability, strengthening accountability systems (e.g., budget, service delivery), strengthening the capacity of and addressing incentives within parliaments to hold government agencies accountable, and strengthening audit institutions.31 Donors and international NGOs are encouraging and supporting governments to develop more inclusive governance processes and investing in the capacity strengthening of CSOs to engage in social accountability activities. • Learning what your rights are, and educating the public on these rights. To build confidence in the system, conduct awareness campaigns to develop an understanding that the state has an obligation to meet those rights and increase awareness of the government’s capacity to address those rights.32 • Empowering beneficiaries by involving them in conducting social monitoring activities to gather evidence on how services are provided. Use this information at a strategic time to make evidence-based recommendations. • Mapping formal and informal and national and local entry points to understand the opportunities for accountability in your context. Even in the most authoritarian country contexts, power is “fluid and negotiated.”33 There are people in every country who believe in improved access to FP information and services, and some 27what is social accountability of them may be government officials within the MOH, Members of Parliament sitting on the Parliamentary Health Committee, or religious and traditional leaders. • Leveraging elections to monitor performance against electoral platforms and hold politicians accountable. 2.4 Lessons learned from social accountability efforts Although social accountability is an emerging field, experiences to date reveal several key points for implementors to keep in mind: • Designing social accountability interventions requires a political economy analysis. This illuminates the power relationships and incentives between different groups in society—assessing informal institutions, sociocultural practices and potential opportunities, and mechanisms and realistic timelines for change.34 The analysis will also reveal that “government” and “civil society” are not homogeneous groups and will help identify entry points and allies for accountability initiatives. • It’s not about the “tools”—Section 3 will describe several social accountability approaches and methodologies, including some common “tools.” However, social accountability experts emphasize that application of these tools needs to be deeply embedded in a contextual analysis and theory of change, and an over- emphasis on “tools” unrealistically depoliticizes a fundamentally political process.35 • Information is essential but not sufficient—citizen empowerment and social accountability activities inevitably require information from government, but transparency does not equal accountability. Information needs to be easily accessed and understood by citizens, and government needs to respond to the citizen voice to actually be accountable. • Strengthening capacity for social accountability needs to happen both among citizens and government officials. Just as civil society needs investment so that it 28 social accountability for FP/RH can monitor and strategically engage with government, government entities and mechanisms also need investment so that they can effectively engage with and respond to citizens. • Successful social accountability efforts routinely engage media to raise awareness of problems, disseminate data and information, and celebrate government response. • Data use can be crucial—if a program initiates a social accountability activity in multiple locales and plans to collect data, it should establish standard indicators where possible for national-level analysis. The data may assist in advancing local- level accountability discussions but can also be used to identify systems issues at the national level. • Institutional changes are needed—social accountability seeks sustainable improvement in democracy and the governance process by institutionalizing dynamic relationships between empowered citizens and responsive governments. • Social movements can provide a vibrant foundation for social accountability efforts. Social movements are collective actions by people who share a common purpose to challenge the status quo. As such, groups advancing certain social accountability efforts may find solidarity with social movements, especially those seeking institutional changes. 29mechanisms of social accountability mechanisms of social accountability 30 social accountability for FP/RH Civil society can engage in social accountability through formal and informal mechanisms, in confrontational and collaborative ways, or through mass action or independent research. Mirroring the “vertical” and “horizontal” accountability definitions in Section 1, one can also think of “invited spaces” and “claimed spaces”—mechanisms instituted by government that engage and involve civil society, and mechanisms or approaches that civil society instigate themselves. In many instances, a mix of approaches will be needed to truly affect change (see Section 6 on maximizing impact). This section outlines a range of mechanisms that CSOs can use to engage in social accountability—some more common than others. 3.1 Citizen involvement in monitoring public services A significant focus on social accountability in health involves the monitoring of public services. It is precisely at the service delivery level where failures in government policy, financing, management, and administration are felt most acutely by citizens, through the absence, or poor quality, of certain services, including respectful care. As such, much of the social accountability literature highlights efforts to engage and mobilize communities to voice their health service delivery needs and elicit a tangible government response. While specific methodologies—such as citizen report cards, community scorecards, social audits, and participatory output monitoring— may differ in implementation, generally these approaches have most or all of the following components in common: • Public education efforts to understand rights to high-quality services and established government standards (e.g., citizen charters). • Collection of information from clients/community members on existing services (e.g., perceptions of quality, fees, accessibility, etc.) using various methods (e.g., audits, surveys, focus group discussions). • Strategies for involving marginalized populations (e.g., anonymous responses, separate focus group discussions). 31mechanisms of social accountability • Face-to-face, constructive engagement with service providers, facility managers, and local government authorities to discuss problems, share data, and develop action plans. • Follow-up and regular data collection and/or group meetings to monitor progress and institutionalize the process. 3.1.1 What are the advantages? CSO monitoring of public services produces real time, grassroots data on the quality of services and barriers to FP use. Data can be used as a benchmark for evaluating improvements over time. If implemented in multiple localities with standardized indicators and collection procedures, data can be used in the aggregate to signal larger health systems issues. Aggregating data from citizen monitoring also provides a mechanism for individuals to voice concerns or complaints without risking retribution. Fundamental to this approach is the dialogue component—constructive engagement that facilitates understanding and action planning between communities, health sites, and local officials. Groups implementing these mechanisms have reported that significant changes can be seen in a relatively short period of time (6–12 months).36 This approach can be implemented independently (vertical accountability) or in collaboration with government officials (diagonal accountability). “The broader the coalition involved in challenging the status quo, the less individual members feel that they are taking a risk by speaking out.” SOURCE: WRA. 2010. Promoting Accountability for Safe Motherhood: The WRA’s Social Watch Approach for Mobilizing Civil Society to Hold Government Accountable. Washington, DC: Futures Group, USAID | Health Policy Initiative, p. 10. When the Uganda White Ribbon Alliance undertook facility assessments and advocacy to increase funding for emergency obstetric care, they found it reduced “blame” for problems and legitimized findings because everyone was involved. —Personal conversation, Ray Mitchell, WRA 32 social accountability for FP/RH 3.1.2 What are the challenges? Community feedback can reveal significant problems and can become personal (e.g., single out specific health providers); and if not well-facilitated, inter-face meetings can quickly shift from collaborative to confrontational. Strong facilitators are needed to manage the process and identify challenges all parties want to solve, even if they have different motivations for doing so. Lead organizations need to consider how they will capture feedback from marginalized populations who may not want to participate in a focus group discussion on FP/RH services, such as young people or key populations (e.g., men who have sex with men, sex workers). Groups embarking on participatory monitoring should have adequate resources to collect the data, facilitate action planning, and conduct periodic follow-up, so that communities see progress when they try to hold their local government and service providers accountable. Government officials must provide a mechanism for receiving and recording this feedback if there is to be true accountability. Further, engaging in dialogue and action planning inherently creates expectations for change. Diverse approaches and terms used in citizen monitoring of health services include: • Citizen Voice and Action (World Vision) • Partnership Defined Quality (Save the Children) • Community Score Card (Care) • Citizen Report Card (World Bank, others) • Social Watch (White Ribbon Alliance) • Community-Based Monitoring Program (Plan International) Adapted from Hoffmann, K.D. 2014. The Role of Social Accountability in Improving Health Outcomes: Overview and Analysis of Selected International NGO Experiences to Advance the Field. Washington, DC: CORE Group. 33mechanisms of social accountability Engaging citizens in monitoring public services requires local trained facilitators— people able to lead and facilitate discussions and deal with conflict. These approaches require varying skills in data collection and research, depending on the methodology used. They can also be time and resource-intensive. For example, the citizen report card methodology requires sample surveys and data analysis, so organizations seeking to implement citizen report cards should have analytical staff with quantitative research capabilities or the resources to partner with another organization that does.37 3.1.3 Other considerations Participatory monitoring of service delivery can be an excellent approach to engage communities and yield visible changes to the quality of health services within a short timeframe. CSOs should actively publicize and applaud instances when participatory dialogue with local leaders has led to positive changes in the quality of health services,38 as these success stories can reinforce the beneficial outcomes of social accountability to all sides involved and also reward responsive governance. Media can be a key ally in this effort by covering the dissemination of data, the implementation process and making of commitments, and the government’s failure to respond in cases of inaction. However, CSOs looking to have a larger public health impact beyond local communities will need to link their local-level efforts, and data they generate, to a national-level process and examination of aggregate data from several locales, so that larger health systems issues (e.g., supply chain management, policies and guidelines, human resources for health) can be addressed. By aggregating citizen feedback and data on quality of services, civil society can catalyze more substantial and sustainable changes to the health system so all citizens benefit. Thus, CSOs should use standard indicators among locales and engage national-level MOH staff throughout the process, particularly if implementing the intervention in more than one district. Another strategy to link these local initiatives to the national level is to engage the Members of Parliament representing the electoral district to ensure policy, programmatic, and financing implications are shared and explored at the national level. 34 social accountability for FP/RH Less direct and more confidential engagement, such as suggestion boxes, hotlines, or short message service feedback, may be more appropriate in some circumstances— for example, when an issue particularly (or disproportionately) affects a marginalized group and when dialogue through face-to-face meetings may be influenced by various cultural, gender, and other power dynamics.39 However, a thorough contextual analysis of how accountability feedback systems may operate in a given context is needed, as anonymity does not guarantee diverse feedback. For example, in Pakistan, Save the Children found that due to illiteracy or lack of access to phones, women did not provide feedback via suggestion boxes or hotlines;40 and a review of the international Federation of Red Cross/Red Crescent’s beneficiary communications in Pakistan found that the location of some suggestion boxes might be a barrier to their use.41 CSOs engaging in participatory monitoring of health services should consider strengthening formal quality improvement processes more generally as a longer- term goal. For example, India launched its National Rural Health Mission in 2005 and incorporated community-based monitoring as part of the mission’s accountability framework. This institutionalized a process for communities to give direct feedback on health services. Although implementation has met with some challenges, it has also reportedly led to improvements in service delivery. When government shows leadership in institutionalizing civil society participation in monitoring the quality of health services, it improves the likelihood of operating at scale, sets an expectation that such processes will have some resources and be routinely implemented, and encourages receptiveness to community feedback among providers and local health administrators. Finally, CSOs should note that many tools for participatory monitoring already exist and have been used in multiple country contexts. As such, groups embarking on this work have a wide range of resources from which to draw and adapt, thus avoiding “reinventing the wheel” (see the Resources section). 35mechanisms of social accountability Institutionalizing citizen monitoring in Guatemala: OSARs In Guatemala, independent civil-society-led bodies called OSARs (Observatorios en Salud Reproductiva, or Reproductive Health Observatories) have been established at both the national and local departamentos levels (similar to a state/ province). These groups, created through a memorandum of understanding with the government and financially supported by donor funding, focus on accountability, monitoring, and data collection for reproductive health in Guatemala. The body serves as a “watchdog” to monitor reproductive health policy implementation and seeks to empower communities and demand accountability for RH information and services. Although local OSARs tailor their monitoring activities to local priorities, they generally engage in public education (e.g., promoting reproductive rights, reducing sexual and gender-based violence); advocacy and lobbying (e.g., exerting pressure on government for specific policies or legal frameworks); and data collection (e.g., monitoring quality of services or contraceptive stock-outs). See www.osarguatemala.org for more information (in Spanish). 36 social accountability for FP/RH 3.1.4 New frontier Governments can also adopt participatory monitoring of service delivery to assure quality in a decentralized context—by contracting out services to the private sector or as part of healthcare financing mechanisms such as performance-based financing (PBF). PBF is a mechanism whereby facilities and/ or providers are partially funded based on their performance against set standards of quality and number/types of services provided. This mechanism can facilitate accountability in numerous ways, including at the facility level. Because PBF includes quality as one of the dimensions of evaluation, client and community experiences with services can be incorporated into the assessment process, often using surveys, to determine the level of remuneration the facility receives. Client travel and wait time, client perception of confidentiality, client satisfaction with counseling (including questions related to method choice and coercion), cost and availability of FP methods or other supplies at the clinic, and numerous other questions related to quality and equity can all be included in the satisfaction survey. A PBF case study from Burundi describes biannual community surveys and the results presented at community feedback meetings with “provincial and district health authorities, the head of each health facility and the president of the facility health committee, the CBO that conducted the survey, and local administers and governors.”42 While program designers need to consider issues related to the functionality of PBF for family planning,43 incorporating social accountability concepts within PBF could provide some measure of reward for facilities in responding to citizen demands (or sanctions if they do not). 3.2 Influencing and monitoring financing Government budgets are the “translation of government promises into concrete actions.”44 To have an impact, government policies and strategies aiming to reach certain objectives need to be adequately resourced. Civil society can engage in the government budgeting process through: 37mechanisms of social accountability • Analyzing proposed government budgets to determine (1) whether they match stated policy priorities, (2) how they may affect particular issues or stakeholders, and (3) the gaps between funding levels and actual needs • Advocating increased funds for FP-related activities (including establishment of, allocation to, and expenditure of an FP line item in the health budget) • Tracking the disbursement and expenditure of funds to verify they match the allocated amounts in the approved budget • Assessing value-for-money to evaluate whether funding was spent efficiently to achieve the programmatic objectives for which it was intended • Participating in collaborative budgeting and planning (see Section 3.3) Benchmarks: • Abuja declaration sets a target for governments to allocate 15 percent of national resources to the health sector. • World Health Organization estimates a minimum of US$44 per person per year is needed to provide basic, lifesaving services (source: http://www.who.int/mediacentre/factsheets/fs319/en/). • United Nations Population Fund/Guttmacher analysis suggests that meeting the need for modern contraceptive care for all women in developing countries who want to avoid pregnancy would cost, on average, US$10.77 per year per woman (source: https://www. guttmacher.org/pubs/AddingItUp2014.pdf). 38 social accountability for FP/RH Various terms and methodologies can be applied to the larger category of CSO monitoring of public finances: Independent budget analysis/alternative budgets: CSOs research and analyze the proposed government budget and highlight its implications for various issues, programs, or stakeholders. They propose alternative policy priorities, such as reducing spending in one area and increasing spending in another, and project the potential economic and/or social impact of doing so. The purpose is to demystify government budgets so the public can better understand where the money is going and voice how their priorities may differ from those of the government. Common themes include gender/women’s, environmental/“green,” and “pro-poor” alternative budgets. Budget advocacy: Budget advocacy is a general term used within the FP community and may mean different things to different people. It commonly refers to efforts by FP advocates to convince government to establish a dedicated line item for family planning in the national budget and increase financial allocations to that line item or related line items. Monitoring FP budget allocations may also involve projections and gap analyses to compare allocated resources and the country’s actual FP/RH funding needs and generate evidence and arguments for increased FP funding. Budget tracking: Government accountability for establishing strong national FP programs is incomplete if those funds are not allocated and disbursed to support meaningful activities that advance FP information and access to high-quality services. The mere allocation of resources to an FP budget line item does not give any real indication of the quality or quantity of FP-related activities that money ends up purchasing. Budget tracking often refers both to budget advocacy activities mentioned above and the Budget tracking is the “last stage of a comprehensive advocacy model.” -Laura Malajovich, IPPF/WHR 39mechanisms of social accountability steps needed to track the disbursement of funds from the national to decentralized levels, as well as efforts to link financial allocations with expenditures (e.g., training, commodities, outreach activities) and analyses on “value for money.” One of the most common methodologies uses the Public Expenditure Tracking Survey (PETS). This is a quantitative exercise that traces the flow of resources through the various levels of government to the service delivery level to determine how much of the allocated resources reach each level and how long they take to get there. The methodology provides insight into such things as cost efficiencies and problems with financial management and execution (corruption and leakage). PETS often complement qualitative assessments of health services (community scorecards/report cards),45 which are designed to assess perceived quality and effectiveness of health services. Linking these two approaches provides a fuller picture of the supply and demand sides of health service provision. 3.2.1 What are the advantages? Government budgets, and the processes through which they are developed and implemented, can seem particularly complex and inaccessible. However, getting involved in monitoring and influencing public finances can have tremendous pay-offs. When we started tracking the sexual and reproductive program for adolescents, we noticed there was no budget. At the central level, the decisionmakers [asserted] we have this great [adolescent RH] program. But we were tracking FP/RH budgets and we went to them and said “there is no budget for it, what do you mean [you have a great adolescent RH program]? How is that possible?” —Esperanza Delgado, Mexfam 40 social accountability for FP/RH CSO monitoring of government financing may reduce some forms of corruption46 and shed light on whether and how government policies and programs are actually financed. In countries with highly decentralized programs and services, monitoring financial flows can illuminate disconnects between national policies and the funding streams that support programmatic implementation at the local level. From an organizational perspective, getting involved in financial monitoring can be an opportunity for CSOs to improve their working relationship with government officials and to be seen as allies and partners. In many cases, CSOs can position themselves as experts and educate government officials on what the budget actually says, given that some program officials within the government may have little involvement in the budget’s preparation. CSOs can draw on their shared interests with FP focal points in the MOH to highlight where funding is not adequate or appropriately spent to meet program objectives. Improved financial allocations and increased resources for certain policy areas can be extremely useful indicators for CSOs that their advocacy activities are having an impact.47 Finally, evidence shows that investing in family planning has high cost-benefit ratios.48 Many data analyses and modeling exercises can show how a dollar spent on family planning can result in significant savings in other areas of health and also in other sectors such as education and water and sanitation.49 Advocating for increased resources for FP programming can have a broad-based and multisectoral appeal, if messaged correctly. 3.2.2 What are the disadvantages? In most countries, the budget process is not well-understood and lacks transparency. Documentation of budget processes is sparse, particularly any guidance or tools that may help CSOs become more involved. In many cases, budget documents and meetings are considered internal/ confidential, and for CSOs to gain entry, sophistication and personal contacts are needed, even in countries with Right to Information legislation. 41mechanisms of social accountability Immersing oneself in budget development and tracking is a full-time, year-round activity that can require several concurrent activities for CSOs: reviewing the previous year’s budget expenditures, tracking the current year’s budget implementation, and preparing to advocate the coming year’s allocations.50 FP advocates may not have the human or financial resources to monitor budgets in this detail. Furthermore, budget processes are often delayed and unpredictable. Sometimes CSOs might find out a strategic meeting is happening the next day or a pivotal person they have scheduled to meet is suddenly unavailable. This makes it difficult for CSOs to plan their advocacy activities and requires them to be highly flexible and responsive to changing situations.51 In addition, it is often difficult to obtain budget information. In some cases, government restricts access to financial documents, or the information is of poor quality or low comprehensibility.52 Often, officials do not even have accurate budget information due to poor financial and data collection systems.53 Thus, most countries do not have a complete picture as to what resources are available for FP programming, since they are contained in multiple budget line items, possibly in different ministries.54 For instance, commodity procurement, provider training, and information, education, and communication/behavior change communication campaigns will be contained in different line items and may come from the national MOH budget or be included in regional or district government budgets. Funding for family life/sex education in schools may be found in the Ministry of Education rather than MOH budgets. Likewise, other government ministries that provide independent health services for discrete populations, such as the department of defense or social security, may also have line items to cover FP services. Hence, budget advocacy requires working with several ministries, including the Ministry of Finance, which is often responsible for preparing initial guidance and formulas for how other ministries budget. Depending on the country context, engaging in financial monitoring can have significant risks, and in some instances, may verge on dangerous.55 Tracking money 42 social accountability for FP/RH flows can reveal inefficiencies, incompetence, mismanagement, and corruption. CSOs may suffer backlashes from public officials and politicians when identified weaknesses are made public.56 Finally, like the Greek myth of Sisyphus, whose punishment was to continually roll a rock up a hill and watch it roll back to the starting point, budget advocacy can seem like a never-ending struggle. Each year as the new budget is drafted, FP advocates must activate and engage their network within and outside of government to ensure funds are allocated to FP-related line items. If not, the FP line item(s) may start with no funding attached or the allocation may be vulnerable to being cut during the budget debate process if FP advocates are not diligent about monitoring budget discussions. Due to population growth and the demographic profile of most developing countries, where each year more and more young people are entering their reproductive years, demands for FP resources will also be increasing. Hence, keeping FP budget allocations at the same level from year to year is simply inadequate to meet this growing need. Thus, for FP advocates, it is not only an annual fight, but one that needs a higher target every year. 3.2.3 Other considerations To be successful at budget tracking work, CSOs must take a partnership approach with local officials. Obtaining financial information may be less dependent on whether the country has official Right to Information legislation and more reliant on personal contacts and relationships with government officials. Taking a collaborative approach may be uncomfortable for some organizations whose advocacy success has been built on external pressure and “watchdog” strategies. Both types of approaches play important roles in social accountability. If a CSO has invested time and effort to build relationships and obtain information, but the budget tracking reveals something that could embarrass the government, one option may be to leak that information to the media or to other CSOs engaged in confrontational strategies so as to not damage the relationship and allow the CSO’s budget tracking efforts to proceed. 43mechanisms of social accountability Partnering with international NGOs can be extremely helpful. For instance, they can offer training and mentoring to engage in budget advocacy (see Resources section). In some country contexts, linking with international NGOs can underscore the legitimacy of a CSO’s budget tracking efforts. Local organizations may find it helpful to have an external party introduce these activities to the government and explain the opportunities for collaboration and mutual benefit that budget tracking provides.57 However, the advantages of partnering with international NGOs are context-specific; in some countries, these partnerships might undermine the local NGOs’ efforts. Budget tracking may also be a somewhat solitary endeavor for a CSO. FP advocacy groups routinely engage in coalition building to advance a particular advocacy goal; this is generally a good idea because there is power in numbers and coalitions are seen as key components of success in advocacy strategies. However, working in coalitions often fits more within an oppositional advocacy strategy rather than a collaborative strategy.58 CSOs will find that budget advocacy and tracking can be effectively done alone or, if needed, in partnership with one or two other groups. “Working to include a dedicated HIV budget line item in Tanzania was accomplished by a small group of CSOs with strong reputations. It required working from the inside, rather than pressuring from outside. In Tanzania, budget advocacy and tracking works more through evidence-based persuasion rather than advocacy strategies based on large broad-based coalitions.” -Peter Bujari, Heath Promotion Tanzania 44 social accountability for FP/RH Many countries have financial allocation and expenditure procedures that retain some flexibility between what is originally allocated in the budget and what is eventually appropriated and spent. For instance, at the state or local level, governors or mayors may have the power to make all allocation decisions within the health sector and/ or to reallocate funds to special projects.59 Not only does the potential divergence between allocations, appropriations, and spending underscore the importance of tracking disbursement and expenditure data, it also provides an opportunity to advocate for FP activities as a priority among subnational decisionmakers. Conversely, district-level budgeting may be largely determined at the central level (e.g., tied grants to local authorities). Only portions of the local budget may be truly open for dialogue and discussion between local authorities and civil society.60 CSOs will need to consider these contexts when deciding to whom and how best they should target their budget tracking and advocacy activities. One successful approach includes pairing local- and national-level interventions. For example, in Tanzania, CSOs conducting budget advocacy at the local level engaged the central government when they faced local-level resistance to releasing budget information. The central government issued a circular to the local government authorities, “reminding them of their obligation to release information according to the existing statutes.”61 3.2.4 New frontier In several countries, FP advocates are quite active in national- level budget advocacy. By 2014, 29 out of 47 countries surveyed by the USAID | DELIVER Project had a dedicated line item in their national budgets for contraceptives,62 making it easier for CSOs to monitor at least one funding pot for family planning. However, FP advocates need to be more involved throughout the spectrum of budget advocacy and tracking activities, which may be more complex and time-intensive (e.g., monitoring national-level allocations to local-level expenditures and analyzing value-for-money). Merely holding governments accountable for funding levels of one line item, typically reserved for contraceptives, will not mobilize all the resources needed for family planning. This may underestimate the resources available for family planning if, as mentioned above, other line items found in other departments also 45mechanisms of social accountability contribute to a holistic FP program. Focusing on one FP line item for contraceptives will also certainly underestimate the resources needed for other important FP program areas such as training, community outreach, and education. Furthermore, in several countries, government decentralization has devolved responsibilities to states, counties, and districts, in effect creating new opportunities for FP advocates to link with local government authorities and influence budget allocations for family planning within subnational budgets. In recent years, a handful of countries have developed national costed implementation plans (CIPs) for family planning.63 These government documents are developed in collaboration with local and international organizations, donors, and other stakeholders to develop consensus and set goals on priority strategies and activities to advance access to and use of family planning. CIPs detail FP program activities and their projected impacts and costs. These plans can be used to leverage resources from donors and international NGOs. There is an opportunity to link budget tracking efforts and activities with developing and monitoring CIPs to ensure the plans are properly financed and funding levels are allocated to the priority activities. For example, in Tanzania, CSOs advocated with the government to include FP-related activity categories in the district-level budget planning tools (PlanRep); these categories are in line with those in the national CIP, making it easier to both mobilize funds at the district level for family planning and track implementation of the CIP.64 More work is also needed to “map public expenditures to pockets of need.”65 Since CIPs may also highlight both demographic and geographic pockets of greater need (e.g., lowest wealth quintile, adolescents, rural areas, specific regions or districts), ensuring budget tracking efforts are linked with CIP implementation could help align funding to these priority areas. 3.3 Collaborative planning and/or management Generally speaking, mechanisms to engage civil society in health sector policy development or program design are time-bound and ad hoc. That is, public hearings, 46 social accountability for FP/RH consultative meetings, or task forces or committees are established to solicit input into defining health priorities, drafting policies, or providing feedback on program implementation.66 These mechanisms are helpful to provide government with information, solicit citizen perspectives, and generate consensus, but they do not create an opportunity for civil society representatives to have a decision-making role. Recognition of both the need for, and the right of, communities to be involved in health policy and program design and implementation is well established. Signatories to the 1994 ICPD Programme of Action committed to promoting private and public sector participation in the design, implementation, and monitoring of population and development policies and programs, with an emphasis on the essential participation of women’s organizations (Chapter 15). Likewise, African government signatories to the 2006 Maputo Plan of Action on SRH promised to promote the involvement of civil society and the private sector in SRHR service delivery within national programs (Strategic Action 1.1.7). 47mechanisms of social accountability To counter this, there are ongoing efforts to enhance civil society participation in health systems planning and management, which both change the dynamics of social accountability and provide new opportunities to ensure government accountability to the communities it serves. Increasingly, governments have institutionalized structures or mechanisms where civil society can routinely engage in participatory planning or management. Perhaps the most common mechanism is a local health committee (for discussion on other mechanisms, see Section 3.3.3). These committees are established to oversee health activities within a certain area.67 They can be at the village, municipal, or district level or a specific health facility, such as a health center committee or hospital board. The committees commonly comprise healthcare workers, civil society representatives, local policymakers (e.g., mayor or councilor), and civil servants (e.g., municipal health officer).68 Participatory planning and management structures exist in all regions. Yet, their mandate, strength, and functionality differ widely. For instance, a 2014 review of health committees in East and Southern Africa noted they exist in policy in 14 countries, though many were not considered highly functional. For instance, information on the legal status and roles/responsibilities of health committees was not available for half of the countries, and most were considered to have low or no capacity to fulfill some key roles, such as monitoring service activities or resources, feeding information back to the community, taking issues to higher (national) levels, and organizing information on community health needs and/or rights violations.69 3.3.1 What are the advantages? Health committees can provide a nexus for civil society participation in and oversight of planning, service delivery, and financial management. This oversight role can ensure services are adhering to national standards and resolve any complaints from the community. In some instances, these committees co-manage health services with the local health facility and may 48 social accountability for FP/RH Examples of collaborative planning and management mechanisms in the health system: Uganda: Health Unit Management Committee Tanzania: Health Facility Governance Committee India: Village Health Sanitation and Nutrition Committee even have a role in the hiring and firing of personnel. They may be involved in budget development or in reporting upward through the health system. In theory, health committees serve as a strong mechanism for promoting and maintaining accountability within the health system because not only are they privy to the front-line realities of health service delivery in their communities, but their composition, which includes representatives from the community, increases the committee’s connection to the people it serves. Likewise, health committees can also serve as a vehicle for disadvantaged or unrepresented groups to highlight specific concerns that may not otherwise be addressed. 3.3.2 What are the challenges? One of the most fundamental concerns regarding participatory planning is the question of who is represented. In many cases, space for civil society representation may be limited to one or two people, making it nearly impossible for them to simultaneously represent a range of constituencies (e.g., women, poor, young people, indigenous people, diverse religious groups, etc.). Further, who chairs the committee, and what tone and process the chairperson establishes, can significantly influence how health committees function.70 How CSO representatives are chosen is also an issue. If civil society representatives are appointed by local government authorities, there is a question as to whether 49mechanisms of social accountability Brazil’s Citizens’ Constitution (1988) guarantees the right to participate in the governance of health, and as a result, local health councils (conselhos) that include civil society representatives have the mandate to approve budgets, plans, and accounts. In Brazil, conselhos municipal de saude (municipal health councils) are spaces for public presentation and discussion of local health plans, and the councils have the legal mandate to demand explanations, approve budgets, and audit accounts. These councils include CSO representatives (50%), municipal staff (25%), and health workers (25%).A study of Brazil’s conselhos municipal de saude found government and civil society stakeholders, without exception, saw these councils as “critical to the very possibility of accountability… an institution worth preserving no matter what difficulties [are] experienced in making it effective.” source: Cornwall, A., S. Cordeiro, and N. Giordano Delgado. 2006. “Rights to Health and Struggles for Accountability in a Brazilian Municipal Health Council.” Chapter 7 in Rights, Resources and the Politics of Accountability, edited by P. Newell and J. Wheeler. London: Zed, p. 21. 50 social accountability for FP/RH “[Effective] participatory planning structures will require back- end investment in the capacity of community members to meaningfully engage in the health planning process.” source: Pathfinder International. 2013. Tracking Planning and Budgeting Processes for Family Planning in Dar es Salaam and Sinyanga Regions. Watertown, MA: Pathfinder International. they will adequately challenge the status quo, given they likely have already- established relationships with local power-holders. “Simply creating spaces for citizen participation is no guarantee that old political practices will not simply be reproduced within them.”71 One suggestion is to develop “participation contracts” between civil society and government to outline terms of reference, establish mutual responsibilities, commit to equal say in decisions, secure participation from marginalized groups, etc.72 Another concern with participatory planning and management is that they are “invited” rather than “claimed” spaces. Their effectiveness as social accountability mechanisms depends on the extent of their mandate, their legal/regulatory status, and the seriousness by which all participants and the government take them. If part of their mandate is to source, budget for, and disburse funding for local health initiatives, health committees need to have some sort of legal status to both receive and account for public funds.73 For example, local health administration committees in Peru, which include elected community members, operate in collaboration with government as private non- profit civil associations with a legal responsibility for administering public funds for one or more primary healthcare facilities.74 Likewise, effective participatory planning and management requires skills development both for the citizens participating and the public officials facilitating the process of participation.75 51mechanisms of social accountability A lack of clarity on the roles of health committee members hampers their work76 and is routinely cited as a major issue in their effectiveness. Yet, participatory planning and management structures are usually under-resourced, which undermines both the effectiveness and legitimacy of the mechanism; if the government does not invest in and support these mechanisms appropriately, people will not take them seriously and they will fail.77 3.3.3 Other considerations Sparse information exists on whether or how participatory planning and/or management specifically influences the robustness of FP/RH programs. Decentralization and local control over health programming does not necessarily mean a community will prioritize FP/RH service delivery. For instance, a 2004 review of community participation in 18 World Bank-supported health sector reform projects in Asia found that only seven included sexual and reproductive health (SRH) services as a component and suggested that decisionmakers need sensitization on these issues. The same report found that low representation of adolescents in participatory planning resulted in narrow SRH programing, focusing on family planning and maternal health rather than the full spectrum of SRH issues. This report cautioned that local power dynamics may present different vulnerabilities for FP/RH programs. For instance, in places where local special interests (i.e., FP opponents) have influence, they may work to negate national progressive FP/RH policies.78 This final point is perhaps most easily illustrated in the Philippines, where, despite national-level government support for FP/RH, the municipality of Manila, bolstered by support from a Catholic lobby, banned modern contraceptives in 2000.79 Because collaborative planning and monitoring structures require joint efforts between government and civil society, government plays a key role in their success. Local public servants are often tasked with providing technical information and management support (including small funds/resources to manage committees). National government support through an MOH or ministry of community development 52 social accountability for FP/RH is also pivotal, including in developing training materials to clarify roles and responsibilities, strengthening the capacity of committee members, underscoring legitimacy, and attracting resources. National facilitators can also be helpful in sharing best practices and lessons learned with communities, thus enabling them to learn from one another.80 Beyond health committees Because both governments and donor communities increasingly see civil society as a partner in development and governance,81 more opportunities and mechanisms have emerged for CSOs and government entities to come together to discuss interests, develop a joint agenda for action, and assess activities and/or progress toward defined health objectives. In the health policy arena, government-sponsored opportunities for social accountability may include: • Annual sector-wide approach (SWAp) reviews—SWAps link the health sector strategy to national strategies for growth, development, and poverty reduction. Reviews include assessing progress against a core set of indicators—which can include FP/RH/maternal health indicators—and looking at resource allocation. For this reason, the health sector review may provide an opportunity for CSOs to contribute to accountability efforts.82 • The International Health Partnership + (IHP+)—The IHP+ Global Compact, signed by international organizations, bilateral agencies, and almost three dozen developing countries, commits to putting internationally agreed principles for effective aid and development co-operation into practice in the health sector. The IHP+ country process can include civil society as a partner in developing and assessing national health plans, developing a country compact, being a watchdog, participating in governance structures, and conducting advocacy.83 53mechanisms of social accountability Successful health committees include: • Terms of reference to clarify mandates, roles and responsibilities, dispute mechanisms, etc., including civil society’s role (e.g., equal say with other committee members). • Broad community representation (diversity). • Elected, limited terms of office. • Regular meetings in accessible spaces. • Meeting minutes, record of decisions, regular feedback mechanism to broader community. • Training of members on roles, responsibilities, basic information, budget interpretation, and other technical skills. • Allowances/transport support for attending meetings (poor members) and site/monitoring visits. SOURCE: Adapted from Howard, G., C. Bogh, G. Goldstein, J. Morgan, A. Prüss, et al. 2002. “Establishing Committees for Implementing Healthy Villages Programmes.” Chapter 11 in Healthy Villages: A Guide for Communities and Community Health Workers. Geneva, Switzerland: World Health Organization; and Coelho, P., V. Schattan, A. Cornwall, and A. Shankland. 2009. Taking a Seat on Brazil’s Health Councils. Citizenship DRC Case Study Series No. 2. 54 social accountability for FP/RH • Parliamentary committees or caucuses—Parliamentarians have a representative, legislative, and resource mobilization role that civil society can leverage to hold government accountable for addressing FP/SRH issues. Most legislative bodies have standing committees under which family planning would fall (e.g., committees on health, population, or gender). Although these parliamentary committees do not include civil society representatives, CSOs can effectively work with the committees by providing evidence/testimonials and organizing joint meetings or public events to (1) raise the profile of FP/SRH issues nationally, (2) call on the MOH (or other entities) to account for a lack of or poorly implemented policies or programs, and (3) generate political will within the legislature for allocating funding to FP/SRH during budget discussions.84 3.3.4 New frontier Many countries have established committees to share information among key FP stakeholders and coordinate FP efforts. The most common are contraceptive security committees,85 but increasingly, countries have established FP technical working groups (TWGs), which have a broader agenda than contraceptive security. These TWGs often fall under the leadership of the MOH and include civil society representatives, including from local and international NGOs; professional associations; and in some cases, the private sector. Their structures, missions, objectives, and effectiveness vary greatly, but they largely serve as a multisectoral information-sharing and program coordination group. An interesting question to ask is whether TWGs can be leveraged for social accountability (see box on page 56). While contraceptive security committees and national FP TWGs are capital-based and nationally focused, there have been some efforts to establish similar coordination mechanisms at the subnational (regional or district) level.86 Recently, Malawi has initiated district health stakeholders’ fora to bring together civil society involved in health promotion and service delivery, alongside the MOH’s District Health Management Teams, to improve health sector planning. This move to enhance district-level participatory planning and management complements decentralization 55mechanisms of social accountability in the health sector and “in essence is strengthening a District Health Sector-Wide Approach (SWAp).”87 These collaborative bodies are usually easily accessible to CSOs, as invitations to attend are often open to all interested. Thus, an opportunity exists for CSOs to engage with TWGs in more collaborative social accountability efforts, such as ensuring follow-up on community issues, discussing results of community scorecards, or engaging in budget tracking. Another opportunity for more participatory planning and social accountability might be local festivals. One suggestion from Ghana is to recognize and leverage traditional festivals as a type of institution and potential social accountability mechanism.88 At traditional festivals in Ghana, local leaders account for progress, community members highlight issues and concerns or appeal for funds for schools/health centers, and local NGOs/CSOs may present on their activities and accomplishments. Since these events bring together decentralized departments of the local government, traditional leaders, community organizations, and a varied cross-section of the population, it is possible views at this forum might be cross-cutting and well-represented.89 Further, large traditional festivals provide the community the opportunity to invite national politicians. Traditional festivals and other community gatherings have historically been used by FP programs to share information, promote family planning, and in some cases, provide mobile services; it may be a natural progression to leverage such events to advance accountability activities alongside these demand-generation interventions. 56 social accountability for FP/RH Is your National FP Technical Working Group a Social Accountability Mechanism? Several countries have established national multisectoral committees or TWGs that address FP/RH issues. Typically led by the MOH and composed of capital-based staff from national and international NGOs/CSOs, donors, and/or health-sector professional associations, TWGs usually serve as a coordinating body to share information, synchronize resources and projects, avoid overlap, and provide a forum to discuss FP priorities. The groups can generate consensus among the FP community, for example, on priority regions or target populations for FP resources/projects; but, can they, or do they, adequately serve as a mechanism to hold government accountable for holistic and rights-based FP programming in the country? Can TWGs be improved to contribute more to accountability efforts? Civil society participating in TWGs can ask themselves the following: • Is the TWG routinely discussing progress on the country’s national or international FP commitments (e.g., progress of FP2020 commitments) and strategizing on how the group can promote progress? • Is the TWG actively promoting FP issues among senior leaders within the MOH and other government ministries so as to encourage political momentum to improve FP programming? • Is the TWG routinely reporting out to and engaging their civil society constituents or other civil society groups not represented so as to increase transparency and 57mechanisms of social accountability promote the TWG as a feedback mechanism to government on FP issues? • Does the TWG ever include Members of Parliament in its meetings, as either targets to be sensitized on FP priority issues or to leverage as partners in holding the executive branch accountable to FP commitments? Leveraging a TWG for accountability efforts has limits, because participating NGOs/ CSOs usually enjoy a collaborative relationship with the MOH representatives in the group, and antagonistic tactics would likely be counterproductive. However, as mentioned under budget tracking and participatory planning, there are many instances when civil society can take collaborative approaches with government counterparts to increase accountability, and there is likely more room in the agendas of TWGs to explore how to do this better. For instance, several countries in Africa have developed CIPs for their national FP program. These plans are usually developed by the government through an existing FP TWG (or one is established for the task). The resulting document outlines national FP activities and funding requirements over a five-year period. Since CIPs represent a consensus on what the TWG members (government, donors, and civil society) have determined as FP priorities, the TWG is often vested in monitoring its implementation, including advocating for more resources from both domestic and donor sources. Galvanizing FP advocacy around a government-endorsed CIP may be an effective, multisectoral, and collaborative approach to holding governments accountable for FP commitments. Note: In some countries, notably Latin America, a similar mechanism exists that has traditionally focused on contraceptive security and thus been more narrowly called contraceptive security committees (Disponibilidad Asegurada de Insumos Anticonceptivos [DAIA]). 58 social accountability for FP/RH 59linking social accountability andlegal action—the “enforceabilty” component of accountability linking social accountability and legal action—the “enforceability” component of accountability 60 social accountability for FP/RH Accountability is typically defined as including two key elements: answerability and enforceability.90 To be considered accountable, one must have an obligation to provide information, answer questions, and justify decisions or actions regarding existing health policies or programs.91 Within a human rights framework, the accountability mechanism must be meaningful and effective in that it can deliver satisfactory and enforceable decisions; states have an obligation to ensure access to justice and remedies for violations of the right to health.92 As described in Section 3, civil society has various approaches and mechanisms it can use to elicit government response to, and redress of, failures to ensure reproductive health and rights. In effect, civil society can often achieve the “answerability” component of government accountability either through collaborative or confrontational strategies. However, a fundamental challenge with social accountability is that there are few avenues of “enforceability” for civil society (the most evident being a democratic election). Civil society can persuade, embarrass, and pressure government to act, but what happens if government fails to respond? Where is the “enforceability” aspect of social accountability? Where social accountability interventions have failed to produce positive impacts, researchers have pointed to a lack of a remedy or redress as a major issue.93 In effect, social accountability approaches can leverage informal mechanisms of accountability (such as public discussions between communities and decisionmakers), but their ability to affect true change may hinge on the ability to link with formal accountability mechanisms. Governments do have legal obligations to facilitate the achievement of better health for their people; this includes upholding and protecting rights, as well as preventing rights violations and “creating policies, structures and resources that promote and enforce rights.”94 Linking social accountability and legal action may be a strategic approach for civil society actors looking to advance FP/RH and rights. 4.1 International and national legal rights to reproductive health, including family planning Numerous international human rights relate to family planning and reproductive health. These include the right to health; right to life; right to liberty and security 61linking social accountability andlegal action—the “enforceabilty” component of accountability of the person; right to privacy; the right to choose the number and spacing of one’s children; the right to be free from cruel, inhumane, and degrading treatment; and the right to information and education.95 Numerous international human rights treaties are relevant, dating as far back as the International Covenant on Economic, Social, and Political Rights (1966), which recognized the right of everyone to “the highest attainable standard of physical and mental health” (Article 12). In 1979, the Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW) specifically recognized and provides for women’s equal access to healthcare services, including family planning (Article 12), as well as FP information (Article 10h). CEDAW further codifies (Article 16e) the earlier political consensus document emerging from the 1968 Tehran International Conference on Human Rights proclaiming that “parents have a basic human right to decide freely and responsibly the number and spacing of their children” (Article 16). Since 188 countries are signatories to CEDAW and other human rights treaties96 that support FP/RH and rights, they are legally responsible for those commitments97 and must periodically report progress to treaty monitoring bodies. The right to health, including access to family planning, and governments’ commitment to help realize this right, has been reaffirmed and expanded on through the past half-century in various ways, including a series of global conferences on population (and development) in Bucharest (1974), Mexico (1984), and Cairo (1994),98 as well as international conferences specifically on women (Mexico, Copenhagen, Nairobi, Beijing). In addition to being signatories to international legally binding documents, countries have constitutions and their own set of policies and regulatory frameworks that outline the rights and entitlements granted to inhabitants of their country. Reproductive rights might be inferred (e.g., as part of the right to health in national legislation) or explicit. For example, Paraguay’s 1992 Constitution not only recognizes the right to decide freely and responsibly the number of children people may have, but also 62 social accountability for FP/RH a right to receive education and reproductive healthcare services.99 South Africa’s Bill of Rights section of its 1996 Constitution includes the right to make decisions about reproduction (Section 12.2) and the right to sexual and reproductive healthcare (Section 27).100 Likewise, the 2010 Kenya Constitution outlines and grants citizens “the right to the highest attainable standard of health, which includes the right to health services, including reproductive health care.”101 In 2010, Chile enacted the Law on Information, Orientation and Provision of Methods to Regulate Fertility, which guarantees the provision of information and counseling on a range of contraceptive methods and requires all secondary schools to provide sexuality education that includes information on contraception.102 Also, most notably, after a decades-long struggle to have reproductive health and family planning recognized as important issues in the country, the Philippines has passed The Responsible Parenthood and Reproductive Health Act of 2012, which guarantees universal and free access to a range of modern contraceptives for all citizens at government health centers.103 4.2 Strategic litigation as an accountability mechanism A government’s failure to respect, protect, and fulfill reproductive rights, through such things as the provision of available and accessible high-quality FP/RH services,104 should, in theory, leave governments vulnerable to legal remedies to hold them accountable. Engaging in strategic litigation can be an effective approach to achieving government accountability. Strategic litigation is the pursuit of legal remedies not just to promote the interests of the individual party to the case but rather to encourage public debate, set important precedents, and bring about wider legal and social change.105 Health areas such as maternal health and HIV have a longer history using the legal and judicial systems as accountability mechanisms.106 However, litigation against government to redress poor service quality or lack of information or services in the area of family planning is fairly new. There are a few recent examples of attempts to 63linking social accountability andlegal action—the “enforceabilty” component of accountability “Legal action of different kinds can advance gender, health, education and other social objectives and needs to be integrated more fully within programs in these sectors. This has significant implications not just for support to governments but also for social accountability investments, too.” SOURCE: Domingo, P. and T. O’Neil. 2014. The Politics of Legal Empowerment: Legal Mobilisation Strategies and Implications for Development. London: Overseas Development Institute (ODI), p. 11. legally enforce a state’s obligation to provide contraception and reproductive health in the courts. For example, in March 2014, the Supreme Court of Zimbabwe ruled the state was liable when a woman was prevented from accessing emergency contraception by doctors and police officers, after she had reported a rape and requested treatment.107 Regretfully, courts have not been as supportive in other countries. For example, in 2009, the Honduras Congress banned emergency contraception; and in 2012, the Honduras Supreme Court upheld this ban, making it a crime to dispense or use emergency contraception.108 In Colombia, legal activists were successful in a constitutional challenge (tutela) against the Inspector General (Procurador) and two deputies for violating women’s right to information.109 In 2012, the court ruled that, indeed, the Procurador’s office had spread misinformation about emergency contraception, misoprotol, and issues surrounding conscientious objection and legal abortion in the country; they were ordered to correct the false information. Manju and Others v. Nepal is an ongoing case where the petitioners claim that Nepal’s government has failed to ensure access (particularly in rural and marginalized communities) to contraceptive methods, information, and services. This leads to a high risk of unintended pregnancies, despite the Nepal constitution granting reproductive rights and healthcare services to all Nepalese women.110 64 social accountability for FP/RH More strategic litigation of FP/RH cases could serve as an advocacy tool and mechanism for holding governments accountable.111 Strategic litigation not only pursues solutions to FP/RH problems as rights violations but also mobilizes civil society in the litigation process to generate pressure and both political and judicial will to resolve the issue. Nonetheless, legal recourse is problematic. It is often costly and may be drawn out over several years. In many places, lawyers may be scarce112 or have little knowledge of the enforceability of reproductive rights. With increased international and national recognition of specific legal rights and state obligations related to reproductive health and contraception, there may be more legal challenges on state’s failure to ensure reproductive health services in the near future. Until then, CSOs seeking to hold governments accountable for ensuring robust FP/ RH programs may consider exploring how other avenues of legal empowerment could enhance social accountability efforts. Legal empowerment is the process in As a result of the 2012 Colombia case, “…emergency contraception continues to be legal and accessible, misoprostol is included in the health plan, institutions are not allowed to be conscientious objectors [to providing FP/RH services], and the National Health Department issued new guidelines on how to provide legal and safe abortions…” SOURCE: Roa, M. and B. Klugman. 2014. “Considering Strategic Litigation as an Advocacy Tool: A Case Study of the Defence of Reproductive Rights in Columbia.” Reproductive Health Matters 22(44): 31–41, pg. 38. 65linking social accountability andlegal action—the “enforceabilty” component of accountability Five principles characterize legal empowerment approaches: 1. They attempt to demonstrate that, even in environments marked by unfairness and arbitrariness, justice (vis-á-vis the state, but also in connection with intra-community disputes, with traditional authorities, and between citizens and private firms) is possible. 2. They combine litigation and high-level advocacy with flexible grassroots tools. 3. They offer a pragmatic approach to plural legal systems, focusing on respect for traditional institutions and seeking solutions that combine the positive aspects of both. 4. They move away from treating people as clients to working to strengthen people’s agency. 5. They focus equally on the rights and responsibilities of citizens. SOURCE: Grandvoinnet, H., G. Aslam, and S. Raha. 2015. Opening the Black Box: The Contextual Drivers of Social Accountability. Washington, DC: World Bank, p. 26. 66 social accountability for FP/RH which poor or marginalized individuals or groups use the legal system and/or redress mechanisms to hold power-holders to account.113 For instance, legal empowerment can draw on national administrative laws that might govern line ministries or punish corruption,114 but it can go beyond litigation to use other mechanisms such as administrative redress, ombudspersons, human rights commissions, mediation/ dispute resolution, and traditional justice.115 Legal empowerment parallels social accountability in that it aims to raise awareness of rights and mobilize and empower citizens; it differs in that it does focus on individual cases or remedies as opposed to “the largely collective social processes” of social accountability approaches.116 Blending legal empowerment efforts with social accountability efforts has the potential to improve the effectiveness of social accountability activities, as “the credible threat of litigation lends weight to the advocacy…”117 Once legal or regulatory gains are achieved through legal empowerment efforts, social accountability initiatives can play a vital role in monitoring implementation or enforcement of these rulings. 67organizational capacity to engage in social accountability organizational capacity to engage in social accountability 68 social accountability for FP/RH Before taking on any new activity, savvy organizations assess how the new effort aligns with their mandate, vision, strategic plan, organizational capacities, and comparative advantage or niche. Yet, there is little information available that outlines in detail what capacities and resources individuals and organizations should have to successfully engage in social accountability. Some documentation of specific social accountability mechanisms or tools describes the process(es) through which the methodology was implemented, but rarely does the documentation outline the level of resources or specific skills/education needed by those implementing. This is largely because social accountability efforts are highly context-specific. This section relays what little information is available on the organizational capacities and resources needed to engage in various social accountability interventions. 5.1 What human resources are needed? To conceptualize, design, and oversee many of the social accountability approaches discussed in Section 3, some literature suggests a fair degree of expertise is required. At a minimum, individuals working on these efforts have usually completed secondary education,118 but, in most cases, these efforts are led by sophisticated national CSOs, or more likely, national offices of international NGOs, with staff holding post-secondary credentials. On describing its experience in Tanzania, one organization stated “[local] CSOs need continuous coaching…[social accountability] tools cannot easily be applied by anyone: an ordinary citizen will not be able to carry out such an analysis, and even local organisations might face constraints.”119 This may be particularly true for groups undertaking methodologically rigorous data collection to assess quality of services (e.g., citizen report cards). However, others claim a fundamental premise of this work is that average citizens can be the backbone of social accountability approaches, albeit assisted by specific experts. For example, participatory monitoring and auditing can easily rely on trained members of the community to collect information and report back to the organizing CSO. “Staff members can easily learn the basics of how to access information and do simple 69organizational capacity to engage in social accountability analysis. The biggest difficulty can be getting the right information…organizations with limited in-house capacity often partner with technically savvy organizations and consultants.”120 Thus, a successful strategy to compensate for a lack of internal capacity may be for grassroots organizations to link to institutions of higher learning to develop systems to track, collect, and transfer knowledge and information.121 FP advocacy organizations interested in engaging in budget analysis and tracking or social auditing should ensure they have a designated staff person able to capture and analyze the information required. Many people involved in budget analysis and tracking are economists or have an accounting background. This level of education is not a pre-requisite but is very helpful. More important than formal education are the following attributes:122 • Comfortable with, and enjoy working with, numbers • Can compare and manipulate figures, such as allocation and spending line items • Have time and patience to search for information and follow up with government officials • Can learn the budget language and converse with those who manage government health accounts Small CSOs, or groups for whom budget tracking/social auditing would be a new activity, who may want to test this type of social accountability activity but may not necessarily have the staff to implement, can consider hiring a consultant. Participatory planning and/or management at the local level will by definition rely on average citizens. For instance, in India, CSO representatives sitting on local health committees come from neighborhood associations or particular interest groups (e.g., women’s group, disabled persons) and are usually of lower- to middle- income status, with only primary or at most secondary school education.123 In Kenya, farmers, teachers, or area chiefs are examples of community representatives who 70 social accountability for FP/RH sit on health facility committees.124 However, engaging with local policymakers may be daunting for some, and community representatives, particularly those of marginalized groups, may be silenced through their own lack of self-confidence, as much as fear of repercussions from other committee members.125 In addition, when members have what amounts to a middle school education (grade 6 or 7), it can be challenging for them to grasp the financial aspect of participatory management.126 It is vital for any CSO supporting participatory planning or management efforts to strengthen the capacity of all members of these committees. For example, in Kenya, members of dispensary health committees are supposed to receive training that builds skills in planning, managing, and governing healthcare, as well as in consensus building and conflict resolution.127 (See also Section 3.3.) These trainings should also include training on gender sensitivity and women’s empowerment, so that women on committees feel empowered to speak freely among their male colleagues. Although some social accountability tools or methodologies require specific expertise, all social accountability efforts involve mobilizing individuals, addressing public officials, and in many cases, engaging with media. At a minimum, CSO staff should have the capacities needed for strategic advocacy efforts, in which many FP-focused CSOs may already engage. These basic advocacy skills include: • Public speaking, facilitation, and the ability to organize and manage meetings • Political savvy and knowledge of how to influence and engage government officials at different levels • The ability to obtain and use evidence to support arguments Since social accountability involves challenging power holders and the status quo, there are both personal and organizational risks in bringing together stakeholders, depending on the issues and the amount of tension inherent to critical dialogue. A CSO should know the political, social, and institutional risks of working on these 71organizational capacity to engage in social accountability issues. For activities requiring community-government dialogue, a CSO should ask itself whether it can play the role of neutral convener and be confident its role would not exacerbate any animosity between stakeholders.128 Further, programmatic documentation universally reports that social accountability activities are time intensive, and as such, any CSO should ensure it has adequate staffing for any interventions and necessary follow-up. 5.2 What financial resources are needed? It is virtually impossible to generate guidance on the financial costs associated with social accountability efforts because few project descriptions include cost components. Also, CSOs may implement similar social accountability interventions but with varying size and scale. Finally, prices for labor and other inputs are not often comparable across countries. However, for illustrative purposes, note that a World Bank guidance document on how to incorporate social accountability interventions in projects provided sample cost data on the community scorecard, citizen report card, and public expenditure tracking surveys conducted in South Asia that ranged from US$15,000 to US$55,000.129 The Health Policy Project in Malawi works with parliamentarians to advocate for increased FP allocations to the national budget and estimates staff time, materials development, and meetings with parliamentarians and other stakeholders to be approximately US$15,000– US$20,000 per year, with additional costs shared by other partners. A report on supporting decentralized planning in Tanzania estimated the costs to implement the bottom-up, government-led, participatory planning process called Opportunities and Obstacles to Development (O&OD) to be US$30,000–US$75,000 per district.130 Like many health interventions, social accountability activities can be designed and implemented to align with available funds, but CSOs must first ensure they are selecting the most strategic social accountability approach(es) to affect the change they want (see Section 2.2) and then plan, staff, and fundraise accordingly to ensure the interventions are implemented effectively. 72 social accountability for FP/RH Social accountability activities that aim to engage citizens at the grassroots level will need to factor communication needs into their planning and costs. While use of mobile phones and the internet is expanding rapidly, consistent access to the internet may be still beyond the reach of many communities, and different groups may have uneven access to mobile phones (e.g., poorest of the poor, women, etc.). Mobilization efforts and face-to-face meetings will still be needed, and these costs can be a large part of a social accountability budget.131 Even routine local meetings may have some costs. For instance, health facility committees in Kenya often pay their members a sitting allowance for each meeting, funded from the facility’s revenue from user fees; this payment ranges from approximately US$1–7.132 However, face-to-face planning meetings and dialogue reduce suspicion and build support for social accountability activities on all fronts. While this adds to program costs, cutting corners in the number or extent of stakeholder meetings could ultimately be problematic and counter-productive to the goals of the initiative.133 In cases where standing meetings are required, or a network is established, momentum can be maintained with minimal resources by rotating responsibility for hosting and chairing meetings, so that ownership is built among all members of the group and costs are contained for “secretariat” functions.134 73maximizing the impact of social accountability efforts maximizing the impact of social accountability efforts 74 social accountability for FP/RH Generally speaking, seasoned FP advocates assert that comprehensive advocacy strategies that combine a number of advocacy approaches are the most likely to achieve desired goals. This is because achieving changes in policies, programs, or institutions usually happens because of several converging factors, and demand for change may be public-, private-, evidence-, or rights-based. The same can be said for social accountability efforts. One social accountability approach can be complemented by another social accountability approach. For example, the White Ribbon Alliance describes linking public demonstrations (vertical accountability) with community representatives engaging in government-led public hearings (diagonal accountability). The visual and vocal display of demonstrators showing widespread support for an issue helps reinforce the one community voice present inside a government meeting.135 Another example of combining strategies comes from the fishers union in Mwanza, Tanzania.136 Facing a 100 percent increase in the fish market levy, the fishers union collected data showing the fish market contributed 3–16 percent of local revenues; yet, the union was not invited to be part of the city council’s participatory planning and budgeting process. When local government refused its request for inclusion, the fishers union organized a public hearing. When the public hearing still produced no results, the fishers union resorted to a civil disobedience action—refusing to pay taxes. Eventually, local government conceded to keep the levy at its original level and invited the union to participate in future local planning exercises. The publication of monitoring results in the media was a significant factor of success, because visibility forced officials to release information or take meetings with certain groups when previously they were unwilling to do so.137 As CSOs explore multiple strategies, they also need to consider vertically integrated social accountability activities.138 Pressure at one level of government (e.g., local) may allow government to shift responsibility to another level (e.g., national, international). However, by exerting mutually reinforcing pressure at multiple levels, CSOs can help prevent government from evading accountability. 75maximizing the impact of social accountability efforts Members of Parliament: Targets of or partners in social accountability? Certain decisionmakers may be both targets of advocacy for social accountability goals and strong advocacy partners in holding government accountable, depending on the stage of advocacy or the social accountability goal. For instance, Members of Parliament may be targets of advocacy to hold governments accountable for budget allocations, but they, particularly those on a health committee, are often strong allies in efforts to hold government entities accountable for effectively implementing FP/ RH programs. Members of Parliament are strong allies because they have procedural and legal tools available to them to hold government departments to account (horizontal accountability, such as holding a hearing) that CSOs do not. Likewise, at the decentralized level, mayors and/or district health officers may be at first targets of CSO efforts to increase local commitment to FP programming, but if found to be supportive, these individuals are also key to advocating for improved programs and/or increased budget allocations within district plans. 76 social accountability for FP/RH In a review of its Health Policy Action Fund small grants program, IHP+ found that grantees working at all different levels (local to national) were most effective. This was due to a variety of reasons. First, while implementation of health policy happens at the local level, information and results of that health policy need to feed back to the national level. Second, local presence increases a CSO’s credibility with the government, and it ensures that the CSO is better able to represent the public’s point of view.139 Thus, social accountability approaches that focus on local-level changes, particularly in service delivery, need to also consider how they can work “upward”—to aggregate data and convene supporters to advocate for changes at the health system level. But this may also require additional skills—skills to deal with higher government levels and build alliances with other NGOs from other areas or at the national level.140 Finally, donors and international NGOs investing in social accountability interventions need to invest in both sides of the equation. While strengthening CSOs’ ability to hold governments accountable is sorely needed, so too is investment in strengthening government’s ability to respond. Government institutions need resources and capacity development to be able to respond to requests for information, engage in interactive forums, and revise policies based on citizen feedback. The Tanzanian Policy Forum’s experience with Social Accountability Monitoring suggests that “usually government institutions are not used to receiving complaints and do not know how to handle them in a professional and responsive way and thus become defensive.”141 Policy Forum in Tanzania included government officials in social accountability monitoring trainings to raise their awareness and sensitize them to the purpose of the monitoring and the types of information being sought. This approach improved government officials’ understanding and “they were more open to collaborating and finding solutions.”142 77social accountability—pivoting our FP programming social accountability— pivoting our FP programming 78 social accountability for FP/RH The field of family planning is a mature discipline within development work. Over several decades, program designers and implementers have learned how to design and implement holistic FP programs to ensure access to high-quality FP services, strengthen health systems to support an enabling environment, and inform and engage individuals and communities—all to ensure women and couples are able to meet their reproductive intentions. With programmatic experience combined with substantial research, FP programmers usually know what needs to be done and how to do it. What FP programs lack most often is not the knowledge on what to do, but rather the financial resources and the political will to do what must be done and the strong systems to hold policymakers, program managers, and service providers accountable for implementing high-quality FP programming. For these reasons, the field of SRH should explore more fully how social accountability strategies and mechanisms could advance family planning by engaging civil society broadly and undertaking transformative approaches to eliciting government accountability. Holistic and comprehensive FP programming already includes many concepts and approaches fundamental to social accountability, and many of the skills and resources needed to implement social accountability activities are similar to those used in FP advocacy and community engagement efforts. Therefore, it is not a stretch for the FP community to explore and integrate social accountability activities into FP programming. For instance, when strengthening services, FP programs routinely include Quality Assurance/ Quality Improvement interventions, such as supportive supervision visits, to ensure providers are delivering high-quality services and supervisors hear about issues being experienced at the facility level. When programs formally and regularly include community feedback (face- to-face meetings or through suggestion boxes) as part of quality assurance/improvement efforts, this introduces a more deliberate social accountability element to the program. Likewise, to generate demand for family planning, programs often support women or men’s discussion groups to increase knowledge, change social norms, and provide peer support. These are “safe space” discussions, usually facilitated and/or linked to a radio program, where participants share their experiences, talk about the positive aspects of 79social accountability—pivoting our FP programming family planning, and discuss barriers or challenges to use. However, some barriers to FP use may be less social and more related to the health system (e.g., cost of methods, stock-outs, etc.). By inviting local officials to hear about some health systems issues that may have emerged from these discussions, FP programs could easily add an accountability element to this type of intervention. With added attention to how an intervention is structured, or how data are used, crowdsourcing information for systems strengthening can also support social accountability. For example, when FP programs work to strengthen the commodities supply chain (e.g., forecasting, procurement, distribution, etc.), involving citizens in reporting experiences with contraceptive stock-outs at facilities using the short message system (SMS) or web- based technologies not only improves efficiency and robustness of data, but increases transparency. What will differentiate this approach as a social accountability intervention from routine data collection/monitoring and evaluation will be whether the intervention can incorporate other key concepts of social accountability, such as increased dialogue with communities on how the stock-out information is being used to improve services, as well as sanctions if poor performance or wrongdoing is exposed.143 Although many FP interventions have the potential to be adapted to include social accountability elements, FP practitioners must first embrace the notion that embarking on social accountability efforts is a fundamentally political endeavor that will “challenge powerful interests that benefit from lack of transparency, low levels of institutional responsiveness, and poor protection of citizens’ rights.”144 Thus, the FP/RH community needs to learn more about governance issues and reach out to good governance experts for assistance with integrating accountability activities into their programs. The most effective approaches will be those that harness current momentum within civil society and build on existing systems, structures, and government and citizen initiatives.145 Finally, this will require pivoting from a public health to a democracy and governance development perspective, introducing new FP programming objectives, timelines, and indicators of success. 80 social accountability for FP/RH 81resources resources 82 social accountability for FP/RH GENERAL SOCIAL ACCOUNTABILITY RESOURCES World Bank Social Accountability E-Guide https://saeguide.worldbank.org/ • Guidance on how to integrate social accountability into development projects. World Bank Social Accountability Sourcebook http://www.worldbank.org/socialaccountability_sourcebook/ • Online resource on social accountability with tools and resources, as well as country case studies on use of specific methodologies. The Global Partnership for Social Accountability http://www.thegpsa.org/sa/ http://www.thegpsa.org/sa/Data/gpsa/files/gpsa_note_1-creating_space_for_social ac- countability.pdf • Website with several key resources including key questions to identify strategic account- ability found on page 6 here: http://www.thegpsa.org/sa/Data/gpsa/files/gpsa_note_1-cre- ating_space_for_social_accountability.pdf The World Bank ARVIN Framework http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTSOCIALDEVELOPMENTEXTP- CENG/0,contentMDK:20529003~pagePK:148956~piPK:216618~theSitePK:410306,00.html. • A tool to help assess the enabling environment for civic engagement. Powercube http://www.powercube.net/ • An online resource for understanding power relations and social change. GSDRC—Applied Knowledge Services http://www.gsdrc.org/ • A website that offers a range of resources on governance, including social accountability. CITIZEN MONITORING OF HEALTH SERVICES Citizen Report Card (CRC) Learning Toolkit www.citizenreportcard.com • Online self-learning course for implementing CRCs; Module 2 includes nine critical factors 83resources for a CSO to consider about its context before deciding whether a CRC is an appropriate social accountability mechanism to further its work. Community Score Cards Implementation Guidance Notes http://governance.care2share.wikispaces.net/file/view/FINAL-CSC%20Guidance%20 Notes_June%202013 pdf/441019066/FINAL-CSC%20Guidance%20Notes_June%202013.pdf • Technical guidance from CARE CSC experts. The Community Score Card (CSC): A generic guide for implementing CARE’s CSC process to improve quality of services http://governance.care2share.wikispaces.net/file/view/CARE%20Community%20Score%20 Card%20Toolkit.pdf/433858992/CARE%20Community%20Score%20Card%20Toolkit.pdf BUDGET ADVOCACY AND TRACKING International Budget Partnership http://internationalbudget.org/ • Online resources for CSOs involved in budget monitoring, including web pages on how to get started doing budget work. • Our Money Our Responsibility—A citizen’s guide to monitoring government expenditures is available in several languages • Open Budget Survey—Data on public access to budget information and analysis of oversight institutions IPPF-WHR Handbook for Budget Analysis and Tracking in Advocacy Projects https://www.ippfwhr.org/sites/default/files/advocacy-budget-eng-final.pdf • Tool to help advocacy NGOs incorporate activities for monitoring and analyzing public resources into their advocacy projects. IPPF-WHR Handbook for Analyzing Public Budgets in Sexual and Reproductive Health https://www.ippfwhr.org/en/publications/handbook-for-analyzing-public-budgets-in- sexual-and-reproductive-health • Guide on how to analyze a public budget from a sexual and reproductive health perspective, including how to identify relevant data and where to find it; geared toward people who are not budget specialists. 84 social accountability for FP/RH Public Expenditure Tracking Survey Manual http://www.unicef.org/vietnam/PET_MANUAL_TA.pdf • Details on designing and implementing PETS easily generalizable to other countries; developed by the Viet Nam Ministry of Planning and Investment and United Nations Children’s Fund. PETS and Quantitative Service Delivery Survey (QSDS) Guidebook http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=r- ja&uact=8&ved=0CCEQFjAA&url=http%3A%2F%2Fpets.prognoz.com%2Fprod%2FGet- GuidlinesDocFile.ashx%3Fdata%3D1&ei=Sz4DVfk4g5o22qGAgAg&usg=AFQjCNFEdQ- 23JW4SyPUhOk_3nnZuhjNe9Q&bvm=bv.88198703,d.eXY • Methodological guidance and sample indicators for implementing PETS and QSDS. Family Planning Costed Implementation Plans Toolkit http://www.familyplanning2020.org/cip • Tools and resources for developing a national, costed FP strategy (roadmap) for achieving FP goals; a CIP can provide rationale and focus for FP budget advocacy. Health Finance and Governance Project https://www.hfgproject.org/tools-civil-society-health-governance/?utm_ source=HS2020%2FHFG&utm_campaign=c68a02529e-HFG_Newsletter_77_7_2015&utm medium=email&utm_term=0_fe52882f0b-c68a02529e-143837053 • Tools to help civil society engage in health finance and governance, including an “entry point mapping” tool. PARTICIPATORY QUALITY IMPROVEMENT Community COPE http://www.engenderhealth.org/files/pubs/qi/toolbook/commcope.pdf Partnership Defined Quality http://www.savethechildren.org/atf/cf/%7B9def2ebe-10ae-432c-9bd0-df91d2eba74a%7D/ PDQ-Manual-Updated-Nigeria.pdf 85resources PARTICIPATORY MONITORING Information on India’s Village Health and Sanitation Committees, including a handbook for members http://nrhm.gov.in/communitisation/village-health-sanitation-nutrition-committee.html Family Planning and Reproductive Health Indicators Database, Repositioning Family Planning indicators http://www.cpc.unc.edu/measure/prh/rh_indicators/specific/repositioning-family-planning • Nine program indicators to monitor progress in increased stewardship of and strengthened enabling environment for effective, equitable, and sustainable FP programming. Contraceptive Security Indicators http://deliver.jsi.com/dhome/whatwedo/commsecurity/csmeasuring/csindicators • USAID | DELIVER Project’s contraceptive security survey of 47 countries conducted annually; data available for 2009–2014. Contains information on technical working groups and budget line items. OTHER RESOURCES The Family Planning Advocacy Toolkit https://www.k4health.org/toolkits/family-planning-advocacy/country-or-regional-studies- influencing-policy • Online resource documenting several country examples of FP advocacy. Regional organizations working with parliamentarians on FP/population issues: • Asian Forum of Parliamentarians on Population and Development, http://www.afppd.org/ • Inter-American Parliamentary Group on Population and Development, https://www.iapg- gpi.org/ • Partners in Population and Development Africa Regional Office, http://www.ppdafrica.org/ Raising the Profile of HIV and AIDS in Your Parliament http://www.ipu.org/pdf/publications/hiv-aids-guide-e.pdf • A resource for parliamentarians and CSOs, published by the Inter-Parliamentary Union. 86 social accountability for FP/RH endnotes and references 87endnotes and references 1 See Section 4 for more information. 2 See http://www.familyplanning2020.org/. 3 Sedgh, G., S. Singh, and R. Hussain. 2014. “Intended and Unintended Pregnancies Worldwide in 2012 and Recent Trends.” Studies in Family Planning 45(3): 301–314. Available at http://www.guttmacher. org/pubs/journals/j.1728-4465.2014.00393.x.pdf. 4 See http://www.oecd.org/development/effectiveness/busanpartnership.htm. 5 Grandvoinnet, H., G. Aslam, and S. Raha. 2015. Opening the Black Box: The Contextual Drivers of Social Accountability. Washington, DC: World Bank. 6 World Health Organization (WHO). 2012. National Accountability Mechanisms for Women’s and Children’s Health. London: HLSP. Available at http://www.who.int/pmnch/topics/part_publications/ national_accountability_mechanisms.pdf; also see http://www.who.int/woman_child_accountability/ about/coia/en/. 7 United Nations Development Programme (UNDP). 2010. Fostering Social Accountability: From Principle to Practice. Guidance Note, August 2010. Oslo: UNDP. Available at http://www.undp.org/ content/dam/undp/library/Democratic%20Governance/OGC/dg-ogc-Fostering%20Social%20 Accountability-Guidance%20Note.pdf; and Brinkerhoff, D. 2004. “Accountability and Health Systems: Toward Conceptual Clarity and Policy Relevance.” Health Policy and Planning 19(6): 371–379. 8 Brinkerhoff, D. 2004. “Accountability and Health Systems: Toward Conceptual Clarity and Policy Relevance.” Health Policy and Planning 19(6): 371–379; and Ghaus-Pasha, A. 2004. “Role of Civil Society Organizations in Governance.” 6th Global Forum on Reinventing Government Towards Participatory and Transparent Governance, May 24–27, 2005, Seoul, Republic of Korea. Available at http://unpan1. un.org/intradoc/groups/public/documents/un/unpan019594.pdf. 9 Affiliated Network for Social Accountability in East Asia and the Pacific (ANSA-EAP). 2010. A Manual for Trainers on Social Accountability. Manila, Philippines: ANSA-EAP. Available at http://www.ansa- eap.net/assets/120/ANSA_EAP_SAc_Training_Manual.pdf. 10 World Bank. 2003. World Development Report 2004: Making Services Work for Poor People. Washington, DC: World Bank. Available at https://openknowledge.worldbank.org/handle/10986/5986. 11 Freedman, L. and M. Schaaf. 2013. “Act Global, But Think Local: Accountability at the Frontlines.” Reproductive Health Matters 21(42): 103–112. 12 Ibid. 88 social accountability for FP/RH 13 For example, the Hewlett foundation supported an R4D 2014 report Accelerating Progress in Family Planning: Options for Strengthening Civil Society-led Monitoring and Accountability. Also, in 2015, DFID awarded a new FP Voice and Accountability Programme, led by Christian Aid, to build civil society’s capacity to hold governments accountable for FP2020 commitments. Further, USAID is supporting FP social accountability activities through such global projects as the Health Policy Project and the Evidence Project. 14 For example, EngenderHealth’s Community COPE, available at: http://www.engenderhealth.org/ files/pubs/qi/toolbook/commcope.pdf. 15 Bjorkman, M. and J. Svenssen. 2009. “Power to the People: Evidence from a Randomized Field Experiment on Community-Based Monitoring in Uganda.” The Quarterly Journal of Economics 124(2): 735–769. 16 Holland, J., A. Thirkell, E. Trepanier, and L. Earle. 2009. Measuring Change and Results in Voice and Accountability Work. Working Paper 34. London: Department for International Development (DFID); McGee, R. and J. Gaventa. 2011. Shifting Power? Assessing the Impact of Transparency and Accountability Initiatives. IDS Working Paper Volume 2011 (383). Brighton, UK: Institute of Development Studies; Ringold, D. A. Holla, M. Koziol, and S. Srinivasan. 2012. Citizens and Service Delivery: Assessing the Use of Social Accountability Approaches in Human Development. Washington, DC: World Bank; Molyneux, S., M. Atela, V. Angweni, and C. Goodman. 2012. “Community Accountability at Peripheral Health Facilities: A Review of the Empirical Literature and Development of a Conceptual Framework.” Health Policy and Planning 27(7): 541–554; Fox, J. 2014. Social Accountability: What Does the Evidence Really Say? GPSA Working Paper No. 1. Washington, DC: World Bank; and Boydell, V. and J. Keesbury. 2014. Social Accountability: What Are the Lessons Learned for Improving Family Planning and Reproductive Health Programs? A Review of the Literature. Washington, DC: Population Council, Evidence Project. 17 Open Society Foundations (OSF). 2011. Community Monitoring for Accountability in Health: Review of Literature. Washington, DC: OSF, p. 6. Available at http://www.copasah.net/uploads/1/2/6/4/12642634/ literature_review_community_monitoring_social_accountability_in_health.pdf. 18 CARE. 2010/2011. The Community Score Card in Tanzania: Process, Successes, Challenges, Lessons Learned. Available at http://governance.care2share.wikispaces.net/file/view/CARE_Tanzania_ CommunityScoreCard.pdf/433865266/CARE_Tanzania_CommunityScoreCard.pdf. 19 Rajani, R., V. Lipovsek, J. Tobias, J. Wales, and L. Wild. 2014. What Role Can Citizens Play in Addressing Stock Outs? Dar es Salaam, Tanzania: Overseas Development Institute and Twaweza. Available at http://www.twaweza.org/uploads/files/CitizensStockOuts-ODI+Twaweza-EN-FINAL.pdf. 89endnotes and references 20 International Planned Parenthood Federation-Western Hemisphere Region (IPPF-WHR). 2012. Holding Governments Accountable: Experiences from Five Latin American Countries. New York: IPPF-WHR. 21 George, A. 2003. “Using Accountability to Improve Reproductive Health Care.” Reproductive Health Matters 11(21): 161–170, p. 162. 22 Fox, J. 2014. Social Accountability: What Does the Evidence Really Say? GPSA Working Paper No. 1. Washington, DC: World Bank. 23 DFID provides a “how-to” note on political economy analysis here: http://www.gsdrc.org/docs/ open/PO58.pdf. 24 Murthy, R. K. and B. Klugman. 2004. “Service Accountability and Community Participation in the Context of Health Sector Reforms in Asia: Implications for Sexual and Reproductive Health Services.” Health Policy and Planning 19(Suppl. 1): i78–i86. 25 Hodel, D. 2013. Meeting Report: Advancing Country Ownership: Civil Society’s Role in Sustaining Public Health. New York and Washington, DC: amfAR; Futures Group, Health Policy Project; International Planned Parenthood Federation (IPPF) Africa Region; and Planned Parenthood Global. 26 Coston, J. 1998. “A Model and Typology of Government-NGO Relationships.” Nonprofit and Voluntary Sector Quarterly 27(358); and Hodel, D. 2013. Meeting Report: Advancing Country Ownership: Civil Society’s Role in Sustaining Public Health. New York and Washington, DC: amfAR; Futures Group, Health Policy Project; International Planned Parenthood Federation (IPPF) Africa Region; and Planned Parenthood Global. 27 Ibid. 28 Ghaus-Pasha, A. 2004. “Role of Civil Society Organizations in Governance.” 6th Global Forum on Reinventing Government Towards Participatory and Transparent Governance, May 24–27, 2005, Seoul, Republic of Korea. Available at http://unpan1.un.org/intradoc/groups/public/documents/ un/unpan019594.pdf. 29 Joshi, A. 2013. Context Matters: A Causal Chain Approach to Unpacking Social Accountability Interventions. Work in Progress Paper. Brighton, UK: Institute of Development Studies. Available at http://www.ids. ac.uk/files/dmfile/ContextMattersaCasualChainApproachtoUnpackingSAinterventionsAJoshiJune2013. pdf. 30 UNDP. 2010. Fostering Social Accountability: From Principle to Practice. Guidance Note, August 2010. Oslo: UNDP. Available at http://www.undp.org/content/dam/undp/library/Democratic%20 90 social accountability for FP/RH Governance/OGC/dg-ogc-Fostering%20Social%20Accountability-Guidance%20Note.pdf; and Frumence, G., T. Nyamhanga, M. Mwangu, and A. Hurtig. 2013. “Challenges to the Implementation of Health Sector Decentralization in Tanzania: Experiences from Kongwa District Council.” Global Health Action 2013, 6: 20983. http://dx.doi.org/10.3402/gha.v6i0.20983. 31 Department for International Development (DFID). 2011. “Implementing DFID’s Strengthened Approach to Budget Support: Technical Note” (technical note). London: DFID. Available at https://www.gov. uk/government/uploads/system/uploads/attachment_data/file/214161/Strengthened-approach- budget-support-Tecnical-Note.pdf; and Department for International Development (DFID). n.d. “Strengthening Accountability in Budget Support Countries—DFID’s 5% Commitment: Briefing Note for Country Offices” (technical note). London: DFID. Available at https://www.gov.uk/government/ uploads/system/uploads/attachment_data/file/67542/5-percent-Briefing-Note-apr11.pdf. 32 UNDP. 2010. Fostering Social Accountability: From Principle to Practice. Guidance Note, August 2010. Oslo: UNDP. Available at http://www.undp.org/content/dam/undp/library/Democratic%20 Governance/OGC/dg-ogc-Fostering%20Social%20Accountability-Guidance%20Note.pdf. 33 George, A. 2003. “Using Accountability to Improve Reproductive Health Care.” Reproductive Health Matters 11(21): 161–170, p. 162. 34 See http://www.gsdrc.org/go/topic-guides/political-economy-analysis-new-/operational-relevance- and-impact-of-pea/rationale-for-pea. 35 Joshi and Houtzager, 2012, as cited in Grandvoinnet, H., G. Aslam, and S. Raha. 2015. Opening the Black Box: The Contextual Drivers of Social Accountability. Washington, DC: World Bank. 36 White Ribbon Alliance for Safe Motherhood (WRA). 2010. Promoting Accountability for Safe Motherhood: The WRA’s Social Watch Approach for Mobilizing Civil Society to Hold Government Accountable. Washington, DC: Futures Group, USAID | Health Policy Initiative; personal conversation, Ray Mitchell, WRA, August 7, 2014; and Muttreja, P. 2014. “Bringing ‘Public’ into Public Health: Experiences, Lessons Learnt, Challenges and Pre-Requisites for Scaling up.” PowerPoint presentation at Strengthening the Evidence Base on Social Accountability for Improving Family Planning and Reproductive Health (FP/RH) Programs experts meeting, London, July 16–17, 2014. International Planned Parenthood Federation. 37 Asian Development Bank and Asian Development Bank Institute. 2007. Improving Local Governance and Pro-Poor Service Delivery: Citizen Report Card Learning Toolkit. Manila, Philippines: Asian Development Bank. Available at http://www.citizenreportcard.com/crc/pdf/manual.pdf. 38 WRA. 2010. Promoting Accountability for Safe Motherhood: The WRA’s Social Watch Approach for 91endnotes and references Mobilizing Civil Society to Hold Government Accountable. Washington, DC: Futures Group, USAID | Health Policy Initiative. 39 Tembo, F. 2012. Citizen Voice and State Accountability: Towards Theories of Change that Embrace Contextual Dynamics. Working Paper 343. London: Overseas Development Institute; and Gigler, B. and S. Bailur. 2014. Closing the Feedback Loop: Can Technology Bridge the Accountability Gap? Washington, DC: World Bank. 40 CDA Collaborative Learning Projects. 2011. Feedback Mechanisms in International Assistance Organizations. Cambridge, MA: CDA Collaborative Learning Projects. Available at http://www. cdacollaborative.org/media/48015/Feedback-Mechanisms-In-International-Assistance-Organizations. pdf. 41 Taylor, L. n.d. Beneficiary Communications and Accountability Review. Geneva, Switzerland: International Federation of Red Cross and Red Crescent Societies. 42 Bhuwanee, K. and L. Morgan. 2012. Community Engagement and Performance-based Incentives: The View from Burundi. PBI Case Studies. Bethesda, MD: Health Systems 2020, Abt Associates, p. 9. Available at http://pdf.usaid.gov/pdf_docs/pnadz322.pdf. 43 USAID. 2010. Performance-Based Incentives Primer for USAID Missions. Washington, DC: USAID. Available at http://pdf.usaid.gov/pdf_docs/PNADX747.pdf. 44 IPPF-WHR. 2010. Handbook for Budget Analysis and Tracking in Advocacy Projects. New York: IPPF- WHR, p. 39. Available at https://www.ippfwhr.org/sites/default/files/advocacy-budget-eng-final.pdf. 45 Waglé, S. and P. Shah. n.d. Public Expenditure Tracking and Facility Surveys: A General Note on Methodology. Washington, DC: World Bank. Available at http://siteresources.worldbank.org/ INTPCENG/1143380-1116506243290/20511062/exptrack.pdf; and Tolmie, C. 2013. “Where Are Our Budgets?” Public Expenditure Tracking Surveys as Tools for Engaging with Civil Society. Bethesda, MD: Health & Finance Governance Project, Abt Associates Inc. Available at https://www.hfgproject. org/wp-content/uploads/2014/04/PETSCivilSocietyBrief.pdf. 46 Schatz, F. 2013. “Fighting Corruption with Social Accountability: A Comparative Analysis of Social Accountability Mechanisms’ Potential to Reduce Corruption in Public Administration.” Public Administration and Development 33: 161–174. 47 See the Family Planning and Reproductive Health Indicators Database, Repositioning Family Planning indicators; Available at: http://www.cpc.unc.edu/measure/prh/rh_indicators/specific/repositioning- family-planning. 92 social accountability for FP/RH 48 Copenhagen Concensus Center estimates achieving universal access to sexual and reproductive health services and eliminating unmet need for modern contraception will return US$120 for every dollar spent. See: http://www.copenhagenconsensus.com/post-2015-consensus/populationanddemography. 49See “Achieving the MDGs” briefs produced under the USAID | Health Policy Initiative at: http:// www.healthpolicyinitiative.com/index.cfm?id=publications&get=Type&documentTypeID=15; also see several analyses conducted under Health Policy Project available at: www.healthpolicyproject.com. 50 Dickerson, D. and A. Ahmed. 2013. Advocacy for Family Planning: Understanding the Budget Process in Two Nigerian States, Cross River and Zamfara. Washington, DC: Futures Group, Health Policy Project. 51 Ibid. 52 Brucker, M., K. Kubica, M. Kway, A. Sizomu, and C. Teti. 2011. Decentralisation, Social Accountability and Family Planning Services: The Cases of Uganda, Kenya and Tanzania. Kampala, Uganda: Deutsche Stiftung Weltbevoelkerung (DSW). Available at http://www.dsw.org/uploads/tx_aedswpublication/2011_Nov_ Decentralisation__social_accountability_and_family_planning_services.pdf; and Decentralization and Local Governance Network (DLGN). 2012. Tanzania: Social Accountability Monitoring (SAM). Zurich, Switzerland: Learning Project Civil Society Participation and Accountability in Local Governance Processes, Swiss Agency for Development and Cooperation. 53 Malajovich, L., M.A. Alcalde, K. Castagnaro, and C. Barroso. 2012. “Budget Transparency on Maternal Health Spending: A Case Study in Five Latin American Countries.” Reproductive Health Matters 20(39): 185–195; also see http://who.int/choice/gettool.pdf. 54 There have been attempts to develop reproductive health subaccounts to ensure that sexual and reproductive health services are funded adequately in national budgets. This exercise is usually done with government, the World Health Organization, and international technical assistance NGOs. For more information, see http://www.healthsystems2020.org/section/topics/fprh. 55 UNDP. 2010. Fostering Social Accountability: From Principle to Practice. Guidance Note, August 2010. Oslo: UNDP. Available at http://www.undp.org/content/dam/undp/library/Democratic%20 Governance/OGC/dg-ogc-Fostering%20Social%20Accountability-Guidance%20Note.pdf. 56 DLGN. 2012. Tanzania: Social Accountability Monitoring (SAM). Zurich, Switzerland: Learning Project Civil Society Participation and Accountability in Local Governance Processes, Swiss Agency for Development and Cooperation. 57 Personal communication with Laura Malajovich, IPPF-WHR, July 2014. 58 Ibid. 93endnotes and references 59 Bossert, T. and J. Beauvais. 2002. “Decentralization of Health Systems in Ghana, Zambia, Uganda and the Philippines: A Comparative Analysis of Decision Space.” Health Policy and Planning 17(1): 14–31; and Dickerson, D. and A. Ahmed. 2013. Advocacy for Family Planning: Understanding the Budget Process in Two Nigerian States, Cross River and Zamfara. Washington, DC: Futures Group, Health Policy Project. 60 Brucker, M., K. Kubica, M. Kway, A. Sizomu, and C. Teti. 2011. Decentralisation, Social Accountability and Family Planning Services: The Cases of Uganda, Kenya and Tanzania. Kampala, Uganda: Deutsche Stiftung Weltbevoelkerung (DSW). Available at http://www.dsw.org/uploads/tx_aedswpublication/2011_ Nov_Decentralisation__social_accountability_and_family_planning_services.pdf; and Inter-American Development Bank (IDB). 2005. Assessment of Participatory Budgeting in Brazil. Washington, DC: Sustainable Development Department, Inter-American Development Bank (IDB). Available at http:// publications.iadb.org/handle/11319/5309?locale-attribute=en. 61 DLGN. 2012. Tanzania: Social Accountability Monitoring (SAM). Zurich, Switzerland: Learning Project Civil Society Participation and Accountability in Local Governance Processes, Swiss Agency for Development and Cooperation, p. 7. 62 See: http://deliver.jsi.com/dhome/whatwedo/commsecurity/csmeasuring/csindicators. 63 Zlatunich, N. 2013. Costed Implementation Plans for Family Planning. Washington, DC: Futures Group, Health Policy Project. Available at http://www.healthpolicyproject.com/pubs/253_ CostedImplementationPlanBrief.pdf. 64 Pathfinder International. 2013. Tracking Planning and Budgeting Processes for Family Planning in Dar es Salaam and Sinyanga Regions. Watertown, MA: Pathfinder International. 65 Dennis, S. 2014. Dollars and Sense: Budget Advocacy for Reproductive Health Event Report. Washington, DC: RH Budget Watch, Population Action International. 66 Murthy, R. K. and B. Klugman. 2004. “Service Accountability and Community Participation in the Context of Health Sector Reforms in Asia: Implications for Sexual and Reproductive Health Services.” Health Policy and Planning 19(Suppl. 1): i78–i86. 67 The mandate of a health committee often also includes community outreach. While this is not an accountability function per se, it can build trust and improve communication among communities, facilities, and local decisionmakers. 68 Murthy, R. K. and B. Klugman. 2004. “Service Accountability and Community Participation in the Context of Health Sector Reforms in Asia: Implications for Sexual and Reproductive Health Services.” Health Policy and Planning 19(Suppl. 1): i78–i86. 94 social accountability for FP/RH 69 Loewenson, R., F. Machingura, B. Kaim, and I. Rusike. 2014. “Health Centre Committees as a Vehicle for Social Participation in Health Systems in East and Southern Africa.” EQUINET Discussion Paper 101 Hararem Zimbabwe: EQUINET, Training and Research Support Centre, Community Working Group on Health, and Medico. 70 Brinkerhoff, D. 2012. Community Engagement in Health Services Delivery and Governance: Experience from the Philippines. Paper presented at International Institute of Administrative Sciences 2012 International Congress, Merida, Mexico, June 18–22, 2012. Available at http://www.inap.mx/portal/ images/pdf/iica/ponencias/1/Brinkerhoff.pdf. 71 Cornwall, A., S. Cordeiro, and N. Giordano Delgado. 2006. “Rights to Health and Struggles for Accountability in a Brazilian Municipal Health Council.” Chapter 7 in Rights, Resources and the Politics of Accountability, edited by P. Newell and J. Wheeler. London: Zed. 72 Murthy, R. K. and B. Klugman. 2004. “Service Accountability and Community Participation in the Context of Health Sector Reforms in Asia: Implications for Sexual and Reproductive Health Services.” Health Policy and Planning 19(Suppl. 1): i78–i86. 73 Loewenson, R., F. Machingura, B. Kaim, and I. Rusike. 2014. “Health Centre Committees as a Vehicle for Social Participation in Health Systems in East and Southern Africa.” EQUINET Discussion Paper 101. Harare, Zimbabwe: EQUINET, Training and Research Support Centre, Community Working Group on Health, and Medico. 74 Hoffmann, K.D. 2014. The Role of Social Accountability in Improving Health Outcomes: Overview and Analysis of Selected International NGO Experiences to Advance the Field. Washington, DC: CORE Group. 75 OSF. 2011. Community Monitoring for Accountability in Health: Review of Literature. Washington, DC: OSF, p. 6. Available at http://www.copasah.net/uploads/1/2/6/4/12642634/literature_review_ community_monitoring_social_accountability_in_health.pdf. 76 Cornwall, A., S. Cordeiro, and N. Giordano Delgado. 2006. “Rights to Health and Struggles for Accountability in a Brazilian Municipal Health Council.” Chapter 7 in Rights, Resources and the Politics of Accountability, edited by P. Newell and J. Wheeler. London: Zed; and Loewenson, R., F. Machingura, B. Kaim, and I. Rusike. 2014. “Health Centre Committees as a Vehicle for Social Participation in Health Systems in East and Southern Africa.” EQUINET Discussion Paper 101 Hararem Zimbabwe: EQUINET, Training and Research Support Centre, Community Working Group on Health, and Medico. 77 Cornwall, A., S. Cordeiro, and N. Giordano Delgado. 2006. “Rights to Health and Struggles for Accountability in a Brazilian Municipal Health Council.” Chapter 7 in Rights, Resources and the Politics of Accountability, edited by P. Newell and J. Wheeler. London: Zed. 95endnotes and references 78 Murthy, R. K. and B. Klugman. 2004. “Service Accountability and Community Participation in the Context of Health Sector Reforms in Asia: Implications for Sexual and Reproductive Health Services.” Health Policy and Planning 19(Suppl. 1): i78–i86. 79 By 2011, Manila relaxed its ban on contraceptives to allow couples to practice modern family planning, but still refused to allow public funds to be used for purchasing or distributing modern contraceptives. See http://www.rappler.com/newsbreak/1695-manila-relaxes-rules-on-birth-control. The passage of the 2012 national RH law made the Manila contraceptive ban illegal. See: http://www.who.int/pmnch/ media/news/2013/20130107_philippines_reproductive_health_law/en/. In 2015, the UN Committee on the Elimination of Discrimination found the contraceptive ban in Manila amounted to a violation of international law (CEDAW). See: http://tbinternet.ohchr.org/Treaties/CEDAW/Shared%20Documents/ PHL/CEDAW_C_OP-8_PHL_1_7679_E.pdf. 80 Howard, G., C. Bogh, G. Goldstein, J. Morgan, A. Prüss, et al. 2002. “Establishing Committees for Implementing Healthy Villages Programmes.” Chapter 11 in Healthy Villages: A Guide for Communities and Community Health Workers. Geneva, Switzerland: World Health Organization. Available at http:// whqlibdoc.who.int/publications/2002/9241545534.pdf. 81 Busan Partnership for Effective Development Co-operation. Fourth High-Level Forum on Aid Effectiveness. 29 November–1 December, 2011. 82 WHO. 2012. National Accountability Mechanisms for Women’s and Children’s Health. London: HLSP. Available at http://www.who.int/pmnch/topics/part_publications/national_accountability_ mechanisms.pdf. 83 For more information on IHP+ and civil society engagement, see http://www. internationalhealthpartnership.net/en/key-issues/civil-society-engagement/. 84 For more information on working with parliamentarians, see: http://www.afppd.org/; https://www. iapg-gpi.org/; http://www.ppdafrica.org/. Also see a resource specific to HIV that may be useful: http://www.ipu.org/pdf/publications/hiv-aids-guide-e.pdf. 85 The USAID | DELIVER Project periodically collects contraceptive security data, including whether a contraceptive committee exists and how often it meets. Its 2014 survey found 42 out of 47 countries had these committees; 38 had NGO representation on the committee. For more information, see http://deliver.jsi.com/dhome/whatwedo/commsecurity/csmeasuring/csindicators. 86 Leahy Madsen, E., M. Gárate, M. Castera, M. Silva, and H. Fortune-Greeley. 2013. Policy Approaches to Enhancing Contraceptive Security in Decentralized Contexts. Washington, DC: Futures Group, Health Policy Project. 96 social accountability for FP/RH 87 Secretary for Health, Government of Malawi. Memo to District Health Officers: District Health Sector Stakeholders Forum Terms of Reference. Ref. No. DPPD/26. Issued: January 28, 2014. 88 Bonye, S. 2011. “The Role of Traditional Festivals in Action Planning, Advocacy and Social Accountability.” World Journal of Young Researchers 1(3): 32. 89 Ibid. 90 George, A. 2003. “Using Accountability to Improve Reproductive Health Care.” Reproductive Health Matters 11(21): 161–170. 91 Brinkerhoff, D. 2004. “Accountability and Health Systems: Toward Conceptual Clarity and Policy Relevance.” Health Policy and Planning 19(6): 371–379. 92 Personal communication with Rebecca Brown, Center for Reproductive Rights, April 2015. 93 Maru, V. 2010. “Allies Unknown: Social Accountability and Legal Empowerment.” Health and Human Rights 12(1): 83–93. 94 Gruskin, S., E. J. Mills, and D. Tarantola. 2007. “History, Principles, and Practice of Health and Human Rights.” Lancet 370: 449–455, p. 450. 95 UNFPA and Center for Reproductive Rights. 2010. The Right to Contraceptive Information and Services for Women and Adolescents. Briefing Paper. New York: UNFPA. Available at http://www. unfpa.org/resources/rights-contraceptive-information-and-services-women-and-adolescents; Center for Reproductive Rights. N.d. Twelve Human Rights Key to Reproductive Rights. Available at http:// www.reproductiverights.org/sites/crr.civicactions.net/files/documents/V4Repro%20Rights%20 Are%20Human%20Rights%20-%20FINAL.pdf. 96 For information on the country status of ratification of human rights treaties, visit http://indicators. ohchr.org/. 97 UNDP. 2010. Fostering Social Accountability: From Principle to Practice. Guidance Note, August 2010. Oslo: UNDP. Available at http://www.undp.org/content/dam/undp/library/Democratic%20 Governance/OGC/dg-ogc-Fostering%20Social%20Accountability-Guidance%20Note.pdf. 98 Overviews of these conferences can be found here: http://www.un.org/en/development/devagenda/ population.shtml. 99 Article 61. Available at: http://jurist.org/documents/constitutions/Paraguay_2011.php. Accessed January 7, 2015. 97endnotes and references 100 Constitution of the Republic of South Africa, 1996; Chapter 2: Bill of Rights. Available at: http:// www.gov.za/documents/constitution/chapter-2-bill-rights#27. 101 Constitution of Kenya, 2010; article 41(3)(a), p.31. Available at: https://www.kenyaembassy.com/ pdfs/The%20Constitution%20of%20Kenya.pdf. 102 UNFPA and Center for Reproductive Rights. 2010. The Right to Contraceptive Information and Services for Women and Adolescents. Briefing Paper. New York: UNFPA. Full text of the Chilean Law No. 20.418: Fija Normas sobre información, orientación,y prestaciones en materia de regulación de fertilidad available at: http://www.leychile.cl/Navegar?idNorma=1010482&idParte=&idVersion=2010-01-28. 103 Available at: http://www.gov.ph/2012/12/21/republic-act-no-10354/. 104 Termed AAAQ (“triple A-Q”) framework; accessible is defined broadly, including both geographically accessible, financially accessible, etc. 105 For a succinct summary of strategic litigation as a human rights advocacy tool, see http://www. endvawnow.org/en/articles/948-engage-in-strategic-litigation.html. 106 For example, in LM and Others v. Namibia, the Supreme Court of Namibia found HIV-positive women’s rights were violated when they were forcibly sterilized in public hospitals. Mexico settled a claim submitted to the Inter-American Commission on Human Rights that they denied Paulina Ramírez access to an abortion, despite her legal right to obtain one in the case of rape. And the Committee for the Elimination of all Forms of Discrimination against Women held Brazil accountable for its failure to prevent a maternal death during childbirth in Alyne da Silva Pimentel Teixeira (deceased) v. Brazil. 107 As reported by Reprohealthlaw, October 29, 2014, at: http://reprohealthlaw.wordpress.com; full text of the court’s decision is available here: http://www.zimlii.org/zw/judgment/actio-legis- aquiliae/2014/22. 108 Center for Reproductive Rights. 2012. “Honduras Supreme Court Upholds Absolute Ban on Emergency Contraception, Opens Door to Criminalize Women and Medical Professionals” (press release). Available at http://www.reproductiverights.org/press-room/honduras-supreme-court-upholds-absolute-ban- on-emergency-contraception-opens-door-to-crim. 109 Roa, M. and B. Klugman. 2014. “Considering Strategic Litigation as an Advocacy Tool: A Case Study of the Defence of Reproductive Rights in Colombia.” Reproductive Health Matters 22(44): 31–41; also see Women’s Link website: http://www.womenslinkworldwide.org/wlw/new.php?modo=detalle_ prensa&dc=382. 98 social accountability for FP/RH 110 Center for Reproductive Rights. 2014. “Manju and Others v. Government of Nepal” (fact sheet). Available at http://reproductiverights.org/en/document/manju-others-v-government-of-nepal. 111 Roa, M. and B. Klugman. 2014. “Considering Strategic Litigation as an Advocacy Tool: A Case Study of the Defence of Reproductive Rights in Colombia.” Reproductive Health Matters 22(44): 31–41; also see Women’s Link website: http://www.womenslinkworldwide.org/wlw/new.php?modo=detalle_ prensa&dc=382. 112 Maru, V. 2010. “Allies Unknown: Social Accountability and Legal Empowerment.” Health and Human Rights 12(1): 83–93. 113 Domingo, P. and T. O’Neil. 2014. The Politics of Legal Empowerment: Legal Mobilisation Strategies and Implications for Development. London: Overseas Development Institute (ODI). Available at http:// www.odi.org/sites/odi.org.uk/files/odi-assets/publications-opinion-files/9008.pdf. 114 Maru, V. 2010. “Allies Unknown: Social Accountability and Legal Empowerment.” Health and Human Rights 12(1): 83–93. 115 Domingo, P. and T. O’Neil. 2014. The Politics of Legal Empowerment: Legal Mobilisation Strategies and Implications for Development. London: Overseas Development Institute (ODI). Available at http:// www.odi.org/sites/odi.org.uk/files/odi-assets/publications-opinion-files/9008.pdf; and Golub, S. 2013. “Legal Empowerment’s Approaches and Importance.” In Justice Initiatives, Open Society Institute, Autumn 2013. Available at http://www.opensocietyfoundations.org/sites/default/files/ justice-initiatives-legal-empowerment-20140102.pdf. 116 Grandvoinnet, H., G. Aslam, and S. Raha. 2015. Opening the Black Box: The Contextual Drivers of Social Accountability. Washington, DC: World Bank, p. 26. 117 Maru, V. 2010. “Allies Unknown: Social Accountability and Legal Empowerment.” Health and Human Rights 12(1): 83–93, p. 85. 118 Decentralization and Local Governance Network (DLGN). 2012. Tanzania: Social Accountability Monitoring (SAM). Zurich, Switzerland: Learning Project Civil Society Participation and Accountability in Local Governance Processes, Swiss Agency for Development and Cooperation. 119 Ibid, p.8. 120 Dennis, S. 2014. Dollars and Sense: Budget Advocacy for Reproductive Health Event Report. Washington, DC: RH Budget Watch, Population Action International. 99endnotes and references 121 UNDP. 2010. Fostering Social Accountability: From Principle to Practice. Guidance Note, August 2010. Oslo: UNDP. Available at http://www.undp.org/content/dam/undp/library/Democratic%20 Governance/OGC/dg-ogc-Fostering%20Social%20Accountability-Guidance%20Note.pdf. 122 Personal conversations with staff from WRA, IPPF/WHR, and Mexfam. 123 Cornwall, A., S. Cordeiro, and N. Giordano Delgado. 2006. “Rights to Health and Struggles for Accountability in a Brazilian Municipal Health Council.” Chapter 7 in Rights, Resources and the Politics of Accountability, edited by P. Newell and J. Wheeler. London: Zed. 124 Goodman, C., A. Opwora, M. Kabare, and S. Molyneux. 2011. “Health Facility Committees and Facility Management—Exploring the Nature and Depth of Their Roles in Coast Province, Kenya”. BMC Health Services Research 2011, 11: 229. 125 Cornwall, A., S. Cordeiro, and N. Giordano Delgado. 2006. “Rights to Health and Struggles for Accountability in a Brazilian Municipal Health Council.” Chapter 7 in Rights, Resources and the Politics of Accountability, edited by P. Newell and J. Wheeler. London: Zed; and Kabeer, N., A.H. Kabir, and T.Y. Huq. 2009. “Quantifying the Impact of Social Mobilisation in Rural Bangladesh: Donors, Civil Society and ‘The Road not Taken’.” IDS Working Paper 333. Brighton, UK: Institute of Development Studies with Citizenship DRC. 126 Goodman, C., A. Opwora, M. Kabare, and S. Molyneux. 2011. “Health Facility Committees and Facility Management—Exploring the Nature and Depth of Their Roles in Coast Province, Kenya”. BMC Health Services Research 2011, 11: 229. 127 McCoy, D., J. Hall, and M. Ridge. 2012. “A Systematic Review of the Literature for Evidence on Health Facility Committees in Low- and Middle-Income Countries.” Health Policy and Planning 27: 449–466. 128 Personal communication, Ray Mitchell, White Ribbon Alliance, August 7, 2014. 129 World Bank. 2012. How, When and Why to Use Demand-side Governance Approaches in Projects. Washington, DC: World Bank. Available at http://documents.worldbank.org/curated/ en/2012/01/16325481/global-use-demand-side-governance-approaches-projects. 130 SNV Netherlands Development Organisation. 2008. Supporting Decentralized Planning in Tanza- nia. Case Studies 2008. The Hague, Netherlands: SNV Netherlands. Available at http://www.google. com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=6&ved=0CD8QFjAF&url=http%3A%2F%2Fwww. snvworld. org%2Fdownload%2Fpublications%2Ftanzania_-_supporting_decentralised_planning. pdf&ei=dp8xVI2-Drb-sAT4tIFI&usg=AFQjCNGNwXfbrgRiMsFdczbg0yWjtI947A&sig2=P9axCf1PCH- HeE-zMEv1pJQ&bvm=bv.76802529,d.cWc. 100 social accountability for FP/RH 131 WRA. 2010. Promoting Accountability for Safe Motherhood: The WRA’s Social Watch Approach for Mobilizing Civil Society to Hold Government Accountable. Washington, DC: Futures Group, USAID | Health Policy Initiative. 132 Goodman, C., A. Opwora, M. Kabare, and S. Molyneux. 2011. “Health Facility Committees and Facility Management—Exploring the Nature and Depth of Their Roles in Coast Province, Kenya”. BMC Health Services Research 2011, 11: 229. 133 Personal conversation, Ray Mitchell, White Ribbon Alliance. 7 August 2015. 134 Brucker, M., K. Kubica, M. Kway, A. Sizomu, and C. Teti. 2011. Decentralisation, Social Accountability and Family Planning Services: The Cases of Uganda, Kenya and Tanzania. Kampala, Uganda: Deutsche Stiftung Weltbevoelkerung (DSW). Available at http://www.dsw.org/uploads/tx_aedswpublication/2011_ Nov_Decentralisation__social_accountability_and_family_planning_services.pdf. 135 WRA. 2010. Promoting Accountability for Safe Motherhood: The WRA’s Social Watch Approach for Mobilizing Civil Society to Hold Government Accountable. Washington, DC: Futures Group, USAID | Health Policy Initiative. 136 DLGN. 2012. Tanzania: Social Accountability Monitoring (SAM). Zurich, Switzerland: Learning Project Civil Society Participation and Accountability in Local Governance Processes, Swiss Agency for Development and Cooperation. 137 Ibid. 138 Fox, J. 2001. “Vertically Integrated Policy Monitoring: A Tool for Civil Society Policy Advocacy.” Nonprofit and Voluntary Sector Quarterly 30(3) [reprinted by Center for Global, International and Regional Studies, UCSC]. 139 International Health Partnership (IHP+). 2013. Review of Civil Society Engagement in National Health Policy Processes Supported Through the Health Policy Action Fund (HPAF) Small Grants Program: Final Report. Washington, DC and Geneva, Switzerland: International Health Partnership. 140 OSF. 2011. Community Monitoring for Accountability in Health: Review of Literature. Washington, DC: OSF, p. 6. Available at http://www.copasah.net/uploads/1/2/6/4/12642634/literature_review_ community_monitoring_social_accountability_in_health.pdf. 141 DLGN. 2012. Tanzania: Social Accountability Monitoring (SAM). Zurich, Switzerland: Learning Project Civil Society Participation and Accountability in Local Governance Processes, Swiss Agency for Development and Cooperation, p. 9. 101endnotes and references 142 Ibid. 143 Davies, T. and S. Fumega. 2014. Mixed Incentives: Adopting ICT Innovations for Transparency, Accountability, and Anti-Corruption. U4 Issue 2014: 4. Bergen, Norway: U4 Anti-Corruption Resource Centre. Available at http://www.u4.no/publications/mixed-incentives-adopting-ict-innovations-for- transparency-accountability-and-anti-corruption/. 144 Institute of Development Studies (IDS). 2006. Making Accountability Count. IDS Policy Briefing Issue 33, November 2006. Brighton, UK: IDS. 145 Ibid. Health Policy Project 1331 Pennsylvania Ave NW, Suite 600 Washington, DC 20004 www.healthpolicyproject.com policyinfo@futuresgroup.com

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