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A three-pronged approach to advocacy for sustainable national funding
FEATURE
A three-pronged approach to advocacy for sustainable national funding Karen Hoehn Independent international development and management consultant, Brussels, Belgium. Correspondence: [email protected]
Abstract: By and large, the financial commitments 179 nations made to the family planning and reproductive health components of ICPD in 1994 were not kept. While donors ramp up support for civil society advocacy in developing countries, in hopes of improving national funding and outcomes, recent trends in advocacy evaluation leave unanswered the broader question of whether/how international campaigning can appropriately and effectively strengthen national-level decision-making. This article provides background regarding the challenges in monitoring developing country contributions; summarizes current donor initiatives to strengthen civil society advocacy; and reviews theoretical approaches to assessing advocacy. The author identifies major advocacy limitations and proposes a three-pronged approach to harmonize international and national advocacy messages for improved, sustained increases in health funding and outcomes, namely, that local accountability is paramount, that national health programmes must be designed as legally binding entitlements, and that pro-health values and norms must be strengthened. © 2014 Reproductive Health Matters Keywords: national budgetary financing, policy and programmes, civil society, advocacy and political process, sexual and reproductive health, family planning, official development assistance, development assistance, evaluation
*The funding categories discussed here (family planning services; reproductive health services; sexually transmitted diseases and HIV/AIDS; and basic research, data and population and development policy analysis) are defined as per the ICPD Programme of Action, Para. 13.14.1–4
gap for the reproductive health and family planning components of the ICPD Programme of Action.2,4 While donor funds lagged, developing country resource allocation became more important. The 2005 Paris Declaration and subsequent Accra Agenda for Action,5 signed by 138 countries, shifted policy discourse and decisionmaking to developing countries in order to increase “ownership” of aid allocation. Many donors dramatically increased the amount of aid provided through direct budget support, which transfers funds in bulk to the national treasuries of recipient governments for allocation through national budget processes.6–9 Nevertheless, despite the best efforts of many organizations, no one knows how much developing countries spend for ICPD-related programming. UNFPA has monitored developing country domestic expenditures since 1997 but has been unable to track progress towards financial targets due to constraints on government funding, staffing and time; poorly developed
Contents online: www.rhm-elsevier.com
Doi: 10.1016/S0968-8080(14)43769-8
When 179 countries adopted the 20-year ICPD Programme of Action in Cairo in 1994, developing countries were expected to provide two-thirds of the total amount required to fund their national programmes, and donor countries agreed to fund the rest.1
Insufficient funds to achieve ICPD aims In fact, donor funding for family planning services and reproductive health research declined immediately after ICPD and funding for basic reproductive health increased only slightly.2–4* Starting in 2001, Belgium kicked off a trend in which eventually 16 donors collectively quadrupled assistance.2–4 Still, in 2011, there remained an estimated US$ 6.6 billion donor funding
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resource monitoring systems; funds pooling; and accounting system decentralization.3 WHO’s Global Health Expenditure Database shows intermittent reproductive health reporting from only three countries since ICPD.10*† Only 11 countries reported reproductive health expenditures under the National Health Accounts RH subaccount methodology, and this reporting seems to have occurred sporadically.14 The William and Flora Hewlett Foundation and Redstone Strategy Group estimated domestic developing country government spending in subSaharan Africa to be 19% of total support spent for family planning and reproductive health from all sources** between 1987 and 2006.15 If this is a true and representative glimpse at the overall picture, it is far less than what was promised in 1994. Given the magnitude of the resource tracking challenge, lack of overall spending data for developing countries is not surprising, but this leaves scholars to infer insufficient funding on the basis of poor reproductive health and family planning outcomes. During the same period, exponential increases in donor funding for sexually transmitted diseases2–4 helped achieve tremendous progress in the fight against HIV/AIDS16 – though those advocates now fear that funding will plateau at current levels.
increases for reproductive health and family planning in-country? Civil society’s crucial role in enabling people to claim their rights, in promoting rights-based approaches, in shaping development policies and partnerships, and in overseeing their implementation was affirmed by 164 governments in 2011.17 As Steven Teles and Mark Schmitt point out, “Very few big social changes happen without some form of advocacy. When these efforts succeed, the results can be transformative.”18 According to Dr Nafis Sadik, Special Adviser to the UN Secretary-General, the ICPD Programme of Action “secret of success” was wide consultation and active participation of civil society. As she puts it: “The physical presence of so many dedicated and committed people, many of them young, many of them women, meant that delegations were well informed about real-world concerns and priorities, and what it would take to make a real and lasting difference…”19 Many donor governments and philanthropists are now ramping up financial support for citizen voice and accountability work to strengthen national commitment to reproductive health and family planning in developing countries. For example:
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Advocacy as a means to increase funding Considering the increased importance of domestic, developing country policy-making for resource allocation, how can international actors strengthen national advocacy to achieve sustainable funding *Liberia, 2007; Malawi, 2003, 2004 and 2005; and Rwanda, 2002. It’s not indicated why reporting exists for only these countries in only these years. †
To address this deficiency, the independent Expert Review Group on Information and Accountability for the UN Secretary General’s Commission on Women’s and Children’s Health recommended strengthening resource tracking, aiming for “at least 50 countries [to] use and have up-to-date and accurate data… by 2013.”11 If the target has been met, the data are not available online as of this writing (May 2014).12 Kenya actually produced poorer resource monitoring information after the target was agreed.13 **ODA, domestic governments, consumers, and HIV/AIDSrelated.
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In October 2013, the European Commission issued a €28 million global Call for Proposals for Non State Actors to improve universal access to reproductive health, with priority for proposals that, among other things support the implementation of public policy and capacity building designed to give better access to sexual and reproductive health; and strengthen local civil society organizations and local authorities. In 2013, the Ministries of Foreign Affairs of the Netherlands and Denmark, and the Packard Foundation, issued a Call for Proposals for a fund manager for a new “Civil Society Fund for Sexual and Reproductive Health and Rights”.20 In 2014, DFID issued a competitive Call for Proposals for a consortium of national civil society organizations, to be led most likely by an international NGO, to strengthen monitoring and accountability for family planning in up to 15 developing countries.21
This surge in donor funding comes from an evidence-based conviction that popular activism and civil society advocacy can effect changes in government policies and funding in specific contexts.22–27
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Theoretical models of advocacy effectiveness If civil society advocacy* can be effective, how can international advocacy strengthen national efforts to increase domestic political commitment and funding for all of ICPD? Wouldn’t it be wonderful to harmonize messages internationally in a way that would strengthen and support national advocacy efforts to increase funding? What insights can structured theoretical models of advocacy effectiveness provide? John W Kingdon argues that a window of opportunity opens when a problem gets policymakers’ attention (problem stream), when a clear way to address the problem is developed (policy stream) and when a political change enables the solution to be developed into government policy (political stream).28 The absence of one of these “streams” can explain why policy change does not happen. This elegant model works well in the national US context for which it was developed. In Washington, DC, most political actors work in relatively close cultural, physical and philosophical proximity to one another, where the underlying rules about how politics works are known (e.g. two-party politics) or learned on entrance to the system (e.g. who really wields power). Global advocacy has much more complex political dynamics. On the world stage, very few simple assumptions can be made about how the vast multitude of actors will respond to the cultural, political, economic and other incentives at play. Jeremy Shiffman proposed a concrete framework on determinants of political priority for global health initiatives that includes 14 factors falling into four major categories of influence in shaping political priority: actor power, ideas, political contexts and issue characteristics. 29 Shiffman’s 2007 tiered level-of-intervention analysis of how to generate political priority for maternal mortality reduction in five developing countries30 is impressive. It identifies and sorts what types of influence are most important at national and transnational levels to help structure global advocacy analysis, as follows:
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transnational influence = norm promotion and resource provision
*Advocacy can be defined in many different ways. WHO provides a helpful working definition: “an organized, deliberate, systematic and strategic process intended to bring about a new or revised social or economic policy or programme.”23
• •
domestic advocacy concern = policy community cohesion, political entrepreneurship, credible indicators, focusing events and clear policy alternatives national political environment = political transitions and competing health priorities.
A recent wave of analyses underscores the dynamism of the complex matrix of advocacy variables that can have an impact. Many of these have their origins in Pawson and Tilley’s 1997 seminal work, Realistic Evaluation, 31 which observed that public policy programme implementation is embedded in social systems; that its effects require the active involvement of social system participants; and that programmes are open systems that cannot be kept constant or isolated from change in either external or internal factors. Teles and Schmitt argue that the very nature of advocacy itself undermines the usefulness of the sophisticated tools usually used to evaluate effectiveness. Among other reasons, they observe that: “The characteristic features of the terrain of politics – chaotic agenda setting, pervasive misinformation, overlapping responsibility – mean that no one metric can capture the reality of influence.”18 Despite its sophistication, Shiffman’s maternal mortality study on changes in political priorities in five countries from the mid-1990s until the early 2000s is itself compromised by such challenges. While the study was being conducted, the Paris Declaration and Accra Agenda for Action launched massive changes to the aid architecture “in relation to how much aid is provided, by whom, to which countries, through which modalities, as well as the purposes to which it is put.”32 With world social and political systems undergoing such rapid change, can large-scale, complex analyses of influence identify how forwardplanning in global advocacy can secure national support? How can any retrospective findings remain valid and relevant, considering the magnitude, complexity and speed of changes taking place in the national and international environment? How much influence and/or power remains with donor governments, how much with domestic developing country governments and how much with other influences altogether? Additional public policy research is required to examine possible answers. Narrowing advocacy assessment to specific advocacy efforts and/or to an advocacy organization’s 45
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“strategic capacity”18 provides a practical response to this complexity. David Devlin Foltz, 33 John Mayne,34 Barbara Klugman35 and others23 emphasize the importance of identifying the implicit theory of change being tested by the implementation of an advocacy project or campaign. They argue that data collection should include not just programme impacts or implementation processes, but also the specific aspects of programme context affecting results and mechanisms creating change. This enables scholars to identify and address the ways in which an advocacy effort has succeeded or failed to address factors that could not be identified prospectively. Keeping this in mind, Klugman35 prescribes seven change categories against which progress in social justice activism and advocacy can be assessed:
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organizational capacity; breadth and capacity of the base of support for an issue; breadth and strength of alliances; the use of data and analysis; degree of coherence around a problem definition and potential policy options; advocates’ access to and influence in policy spaces; and visibility of the issue from the perspective of the advocates.35
This is a helpful model for assessing strategic capacity and the effectiveness of a particular advocacy effort. At the same time, this and related retrospective models leave a gulf between the assessment of a particular advocacy campaign, programme or organization in situ and the broader hope by international supporters of sexual and reproductive health and family planning that changes can be planned globally with plausible evidence for success in strengthening national political commitment. Reviewing the limitations and failures of advocacy in generating sustained funding increases may help point toward solutions.
When advocacy fails The following observations are based largely on my 27 years of practical experience with advocacy – toward the national and state governments of the United States, European governments and the European Union, and country decision-makers in Africa and Asia. Fortunately, 46
many others have had similar experiences, and where available, those observations are included. Policy advocacy does not change value-driven behaviour Advocacy that seeks to impose change not genuinely willed by the people to be affected (i.e. the public) will be of limited effectiveness and/or duration, as participants can always be expected to “game the system” in pursuit of their genuine interests. A great deal of concrete evidence demonstrates how pervasive social and cultural norms affect public policy priorities. Studies by Rose Oronje and others36–40 highlight the importance of social and cultural norms affecting grassroots political priorities and hindering development and implementation of effective sexual and reproductive health and rights policies across Africa. Oronje has shown “just how influential individuals in patriarchal societies can frame sexuality and women in ways that perpetuate and legitimize gender inequality and deny women opportunities to realize their human rights” even when policies are enacted in support of those rights.36,37 Freedman and Schaaf compellingly argue how advocacy that does not address real power structures is doomed to fail,41 and furthermore, that the globalized “best practices approach to implementation…requires evidence generated through studies with experimental designs that, almost by definition, require the nullification of exactly the power dynamics so central to understanding sexual and reproductive health and rights.” I suspect that many advocates around the world would silently or openly agree on both counts, but are trapped, deterred or defeated by the overwhelming momentum and power behind these obstacles. Non-binding international commitments do not drive national budgets Advocacy that focuses on generating international commitments or policies disconnected from legally binding funding mechanisms does not have sufficient power to effect sustained funding toward those commitments/policies. The ICPD Programme of Action is only one example of many international policy commitments whose concomitant national obligations remain unfulfilled by the very governments that signed them. Why? There may be advocates and decision-makers who genuinely believe that governments will naturally make a sustained effort
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to fulfill their commitments. Too often, though, the intensive surge of advocacy effort that goes into producing such non-binding commitments is followed by exhaustion among the campaigners who fought for the best possible declaration and by “thematic burnout” or complacency among political decision-makers who feel they have already done enough by endorsing a statement calling for desired change. Obtaining the funds to implement non-binding commitments requires a separate, additional, and often more difficult advocacy effort, through eternal cycles of budgetsetting by both donors and developing country national governments. Civil society capacity to meaningfully engage in budget advocacy is limited Civil society in many countries does not have sufficient knowledge or capacity to influence budget processes effectively. As observed by the International Budget Partnership (IBP): “Many civil society organizations, journalists, and even parliamentarians lack the basic skills to engage meaningfully with budget issues.” 42 This problem is further compounded by the limited capacity or willingness of many governments to assure the open, transparent, uncorrupt financial management required for democratic governance and accountability. As IBP puts it:
time-limited advocacy grant-giving. Nothing guarantees further momentum toward funding increases when the advocacy campaign or project comes to an end, and often, projects do not last long enough to be able to measure or monitor their real impact.23,27 This places both advocates and their donors in difficult positions. Advocates are forced into the uncomfortable position of trying to convince their donors to perpetually renew grant support in order to protect and sustain results, while at the same time trying to prove: (a) that they have already produced significant, sustainable results even if the debut grant wasn’t of sufficient duration to measure this properly; (b) that the timing of the renewal proposal is equally or even more urgent than before; and (c) that, even if they were already highly successful, something “innovative,” different or new in the methodology justifies grant renewal. On the donor side, these arguments may be difficult to buy. Even supportive donors who understand the need for sustained advocacy funding may find it difficult to convince their own stakeholders and accountability processes that anything should be funded repeatedly or indefinitely.
Unfortunately, capacity-building itself is cyclical: inevitable turnover of political representation and civil society organization staff requires regular renewal of capacity-building with new actors to avoid losing ground.
Advocacy success at national level does not help as decisions are increasingly decentralized to sub-national governments43,44 Decentralization seeks to reduce central influence and promote local autonomy. By changing who has authority and financial responsibility for health services, however, it can have a large impact on health system performance, bad as well as good.43,44 As pointed out above, national/ subnational resource tracking systems in very many countries remain insufficient for effective monitoring. 3,8–14 Similarly, national advocacy capacity rarely extends to the wide range of sub-national decision-making bodies empowered by decentralization, probably because many advocates and advocacy donors are overwhelmed by the information and resource burden required to do this well.
Even when budget increases are secured, annual budget cycles require perpetual advocacy for sustained improvements Civil society can impact funding when budget advocacy is implemented over a long period of time; however, most advocacy is dependent on donors who prefer or are required to provide
Budget advocacy and increases in funding do not assure improvements in outcomes Of course, even when funding increases, poorly spent funds do not improve health outcomes. As the Hewlett Foundation and Redstone Strategy Group report states: “Multiple factors, including donor policies (e.g. tied aid), actual activities
“…citizens have been traditionally excluded from budget decision-making and monitoring, as have been civil society organizations, legislatures, and the media…public budgeting is still conveniently governed by the arcane principle that budget information should be guarded as a state secret, and the process dominated exclusively by the executive. Budget transparency and accountability is often weakest in countries where poverty and inequality are highest.” 42
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funded, governance in recipient countries, and economic cycles can contribute to the success or failure of an investment and ultimate FPRH [ family planning and reproductive health] indicators.”15 Tracking the policy implementation process from budget setting, to disbursements, to programme implementation in the field is required to determine the obstacles to improving reproductive health and family planning outcomes when funding increases. Completing the IBP excerpt from above concisely illustrates this problem: “…The result is a massive leakage of scarce public resources into unnecessary projects, corruption, and ineffective service delivery, undermining efforts to reduce poverty, improve governance, and consolidate democracy.” 42
Three-pronged advocacy approach to achieve sustainable national funding Given the above, achieving sustainable, i.e. lasting, increases in ICPD and health funding at the domestic level argues for a new approach. The following three-pronged advocacy approach could enable international coordination of advocacy messages, while leaving the all-crucial contextualization to those at national level who are most directly affected by the problems to be addressed. 1. Local accountability is paramount Since the content of advocacy must be specifically contextualized for local needs and circumstances in order to gain support and be effective, one universal campaign theme might be ensuring that there are clear processes for democratic accountability at/to the grassroots level. One way to do this is through establishment of subnational community or citizen advisory councils to monitor local progress and push for improvements. Advisory panels in each local area, for example, could provide local authorities with information and recommendations from the community on the public’s reproductive health problems and needs. Regular meetings in each local area would allow residents to discuss pressing issues with decision-makers. Such meetings can also provide an opportunity for local officials to assess the impact of their policies on the community. Such councils are challenging to manage, and yet can produce tremendous value. In developing programmes to manage health systems in several US states, I found it very helpful to create distinct 48
advisory councils for consumers/beneficiaries, for health care providers and for government officials. Operating from the moment of programme design throughout ongoing operations, these advisory councils enabled participants to voice concerns and identify solutions. During policy/programme design, such input can help prevent a wide variety of problems, as seen uniquely from the perspective of each group. During start-up and early implementation, advisory councils can provide quick feedback if things aren’t going well, as well as a venue for managing expectations. During ongoing operations, they can ensure regular feedback to programme managers to inform policy/programme refinements and improvement ad infinitum. Having participants meet regularly with their peers creates a relatively safe space to air concerns, reducing the common power differentials that inhibit some individuals while allowing others to dominate. Disparate views coming from each council can be reconciled through sharing recommendations among them and bringing the councils together for concrete, joint problem-solving. The openness of recommendations can significantly help improve monitoring and accountability for building responsive programmes. An essay presented at the 2011 International Family Planning Conference in Dakar, Senegal, provided preliminary results on a similar type of work implemented in health in Africa. A consortium of non-governmental organizations sought to improve health budgets and policies, including reproductive health and family planning, by taking the following actions at the national and district level in 13 districts in Kenya, Tanzania and Uganda:
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increasing access to information on health and family planning budgets and policies; creating local civil society coalitions for greater voice; organizing education campaigns on civic rights and obligations, as well as the importance of family planning; and initiating dialogue at village, district and national levels to increase transparency in decision-making and allow poor segments of society to have a voice.
Reported results included strengthened advocacy; improved dialogue among community members, civil society organizations and local officials; increased transparency in local government decision-making; and apparent commitment
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to community accountability on reproductive health and family planning.43 The emphasis in both cases was local accountability. There are many examples of both genuine and pro forma civil society advisory bodies at the national level, such as those employed by national governments, donor delegations, or for example by the Global Fund for AIDS, Tuberculosis and Malaria for its Country Coordinating Mechanisms. National advisory bodies have their merits, but in order to operate effectively, their size must be constrained, which inevitably distorts the nature of the discussions. Genuinely local processes are key to translating discussions about policies and funding into results that are verifiably accountable to communities and individuals, regardless of what national party or government holds power. 2. National health programmes must be designed as legally binding entitlements Enacting binding national legislation that entitles people by virtue of financial and/or categorical eligibility to family planning, sexual and reproductive health care and other health benefits can be one highly effective way to circumvent annual budget cycles and bring about sustainable results. Provision of contraception is binding on the National Health Service in Great Britain, for example, and there are many other examples in the social protection mechanisms that currently exist in nearly all wealthy countries and many middle-income countries. In the US, Social Security and Medicare were themselves once unthinkable, but they continue to grow with the ageing of the population and provide minimal protection against poverty. Almost all wealthy countries have some form of social protection to which their citizens are entitled by virtue of their age, disability status, income level or other criteria. As poor countries develop, it is appropriate to ask them to do likewise, in accordance with the human rights imperative to take all feasible steps to respect, protect and fulfill the right to the highest attainable standard of health. Programmes with financial and/or categorical eligibility requirements would be exempt from annual budget authorization and approval processes, with programme funding determined by the number of people who are categorically eligible and the benefits to which they are entitled. Any funding needed to operate the programme which could not be met exclusively through
domestic government revenues in the poorest countries would require supplementation from donor governments.45 Models for how this might work need to be more fully explored. Would pairing national advocacy for legally binding eligibility programmes with international advocacy for a global Framework Convention for Health* or to Universal Health Coverage46,47 generate sustainable change? The devil, so to speak, is in the details, which both require and merit more study and prospective modelling. The usefulness of “legally binding” arrangements, of course, depends on at least two major contingencies. One of these is the effectiveness of the legal systems in question. There are arguably larger and more diverse constituencies around the world invested in improving legal system functioning than seem to be invested in improving sexual and reproductive health. Even if the constituencies supporting and benefiting from strengthened legal systems are not greater, per se, their efforts are largely complementary to the work of ICPD advocacy. Advocacy that successfully results in national legislation entitling people to sexual and reproductive health care could “leverage” the success of efforts to strengthen legal systems for improving sexual and reproductive health. Second, some professionals in the field rightly argue that right-wing political opposition to policies improving sexual and reproductive health mitigates the effectiveness of legally binding entitlement programmes, citing for example contraception and abortion coverage challenges in the US and a recent Swiss referendum to remove abortion from the list of state-reimbursed health services (which, however, failed by a wide margin). This second point leads to the crucial third leg of the proposed approach: the need for relentless, sustained work toward norm change in support of the right to health throughout the world. 3. Pro-health values and norms must be strengthened It has long been known that deep-seated cultural values and norms shape health outcomes, and further, that “religious” opposition to some aspects of sexual and reproductive health is often less clearly grounded in religious doctrine than in engrained habits of thought and practice. As *For more about the Framework Convention, see http://www. who.int/bulletin/volumes/91/10/12-114447.pdf.
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Oronje and others convincingly demonstrate,36–40 even when sexual and reproductive health have “official” support, efforts to improve outcomes can easily be undermined by individual or community values, through the choices people make and actions they take every day. For this reason, culture change – a critical mass shift in social norms – is needed to assure sustained change toward improved outcomes. Klugman observes “in the long term, to sustain policy victories, one needs to build public support for an issue”.35 Unfortunately, culture change and women’s empowerment are often neglected in the search for quick wins and immediate uptake. When neglected, community discourse on the norms and values that impede health – not least women’s power in their families and communities – will always lurk as an undermining factor. The sustainability of local and national civil society advocacy to improve policies and funding can only be strengthened by dogged determination to advance culture change, drawing on excellent resources in the field that already exist, such as the policy framework proposed by Knott et al to DFID in 2008.40
Conclusions The three-pronged approach described here could enable coordination of international advocacy messages in support of “local accountability” and “legal entitlement”, and leave the crucial contex-
tualization to those who are most directly affected by the problems to be addressed. Complementing Shiffman’s observation of norm change as a matter of transnational influence, these messages emphasize pro-health cultural norm change in communities as necessary to achieving lasting results, and address the increased importance of the national context for resource provision. Together, they could enable concrete mechanisms to systematically overcome common, cyclical obstacles and generate sustained results. In principle, they could bridge the gap between policy, funding, implementation and outcomes. Additional research would help identify ways in which aspects of this model have been tried and tested within the field of reproductive and sexual health; whether concrete case studies exist to verify or refute their promise; and enable forward planning to test the model’s underlying components. But even without additional research, as the post2015 landscape unfolds and policy-makers start narrowing options for international agreement, this three-fold approach merits consideration. Acknowledgements The author thanks Gorik Ooms for kicking off this analysis by asking questions, suggesting reading materials and patiently, substantively commenting on drafts; and Dirk Van Braeckel and the International Centre for Reproductive Health at Gent University for their support.
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K Hoehn. Reproductive Health Matters 2014;22(43):43–52 41. Freedman L, Schaaf M. Act global, but think local: accountability at the frontlines. Reproductive Health Matters 2013;21(42):103–12. 42. de Renzio P, Krafchik W. Lessons from the Field: The Impact of Civil Society Budget Analysis and Advocacy in Six Countries. Practitioners Guide. International Budget Project, 2007. 43. Brucker M, et al. Decentralization, social accountability and family planning services: the cases of Uganda, Kenya and Tanzania. International Conference on Family Planning: Research and Best Practices. 29 November−2 December 2011. Dakar, Senegal.
44. World Bank. Health Systems Topics: Decentralization. http://go.worldbank.org/MUFMCLWJR1 45. Ooms G, Mulumba M, Hammonds R, et al. A global social contract to reduce maternal mortality: the human rights arguments and the case of Uganda. Reproductive Health Matters 2013;21(42):129–38. 46. Ooms G. The right to health and the sustainability of healthcare: Why a new global health aid paradigm is needed. International Centre for Reproductive Health Monographs. 2008. 47. World Health Organization. What is Universal Health Coverage? http://www.who.int/health_financing/ universal_coverage_definition/en/
Résumé Les engagements financiers que 179 nations ont souscrits en faveur des composantes de planification familiale et de santé génésique de la CIPD en 1994 n’ont dans l’ensemble pas été tenus. Alors que les donateurs accroissent leur soutien au plaidoyer de la société civile dans les pays en développement, dans l’espoir d’améliorer le financement et les résultats à l’échelon national, les récentes tendances dans l’évaluation du plaidoyer ne répondent pas à la question plus large de savoir si les campagnes internationales peuvent renforcer efficacement la prise de décision au niveau national et de quelle manière. Cet article informe sur les enjeux du suivi des contributions des pays en développement. Il résume les initiatives actuelles des donateurs pour consolider le plaidoyer de la société civile et analyse les approches théoriques à l’évaluation du plaidoyer. L’auteur identifie les principales limites du plaidoyer et propose une approche triple pour harmoniser les messages nationaux et internationaux pour des hausses accrues et soutenues du financement et des résultats en matière de santé, à savoir : la responsabilisation locale est primordiale ; les programmes nationaux de santé doivent être conçus comme des prestations garanties par la loi ; et les valeurs et normes en faveur de la santé doivent être consolidées.
Resumen En general, los compromisos financieros de 179 naciones relacionados con los componentes de planificación familiar y salud reproductiva de la CIPD en 1994 no se cumplieron. Mientras que los donantes incrementan su apoyo para promoción y defensa (advocacy) por parte de la sociedad civil en los países en desarrollo, con la esperanza de mejorar la financiación nacional y los resultados, las recientes tendencias en la evaluación del advocacy no contestan una interrogante general: si las campañas internacionales pueden fortalecer debida y eficazmente la toma de decisiones a nivel nacional y cómo pueden hacerlo. Este artículo expone los antecedentes relacionados con los retos de monitorear los aportes de los países en desarrollo; resume las iniciativas de donantes para fortalecer el advocacy por parte de la sociedad civil; y revisa estrategias teóricas para evaluar el advocacy. La autora identifica las principales limitaciones del advocacy y propone un enfoque de tres componentes para armonizar los mensajes internacionales y nacionales que abogan por mejores y continuos aumentos en la financiación del área de salud y sus resultados: es decir, que la responsabilidad local es primordial, que los programas nacionales de salud deben diseñarse como derechos jurídicamente vinculantes, y que los valores y normas pro salud deben fortalecerse.
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A three-pronged approach to advocacy for sustainable national funding Karen Hoehn Independent international development and management consultant, Brussels, Belgium. Correspondence: [email protected]
Abstract: By and large, the financial commitments 179 nations made to the family planning and reproductive health components of ICPD in 1994 were not kept. While donors ramp up support for civil society advocacy in developing countries, in hopes of improving national funding and outcomes, recent trends in advocacy evaluation leave unanswered the broader question of whether/how international campaigning can appropriately and effectively strengthen national-level decision-making. This article provides background regarding the challenges in monitoring developing country contributions; summarizes current donor initiatives to strengthen civil society advocacy; and reviews theoretical approaches to assessing advocacy. The author identifies major advocacy limitations and proposes a three-pronged approach to harmonize international and national advocacy messages for improved, sustained increases in health funding and outcomes, namely, that local accountability is paramount, that national health programmes must be designed as legally binding entitlements, and that pro-health values and norms must be strengthened. © 2014 Reproductive Health Matters Keywords: national budgetary financing, policy and programmes, civil society, advocacy and political process, sexual and reproductive health, family planning, official development assistance, development assistance, evaluation
*The funding categories discussed here (family planning services; reproductive health services; sexually transmitted diseases and HIV/AIDS; and basic research, data and population and development policy analysis) are defined as per the ICPD Programme of Action, Para. 13.14.1–4
gap for the reproductive health and family planning components of the ICPD Programme of Action.2,4 While donor funds lagged, developing country resource allocation became more important. The 2005 Paris Declaration and subsequent Accra Agenda for Action,5 signed by 138 countries, shifted policy discourse and decisionmaking to developing countries in order to increase “ownership” of aid allocation. Many donors dramatically increased the amount of aid provided through direct budget support, which transfers funds in bulk to the national treasuries of recipient governments for allocation through national budget processes.6–9 Nevertheless, despite the best efforts of many organizations, no one knows how much developing countries spend for ICPD-related programming. UNFPA has monitored developing country domestic expenditures since 1997 but has been unable to track progress towards financial targets due to constraints on government funding, staffing and time; poorly developed
Contents online: www.rhm-elsevier.com
Doi: 10.1016/S0968-8080(14)43769-8
When 179 countries adopted the 20-year ICPD Programme of Action in Cairo in 1994, developing countries were expected to provide two-thirds of the total amount required to fund their national programmes, and donor countries agreed to fund the rest.1
Insufficient funds to achieve ICPD aims In fact, donor funding for family planning services and reproductive health research declined immediately after ICPD and funding for basic reproductive health increased only slightly.2–4* Starting in 2001, Belgium kicked off a trend in which eventually 16 donors collectively quadrupled assistance.2–4 Still, in 2011, there remained an estimated US$ 6.6 billion donor funding
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resource monitoring systems; funds pooling; and accounting system decentralization.3 WHO’s Global Health Expenditure Database shows intermittent reproductive health reporting from only three countries since ICPD.10*† Only 11 countries reported reproductive health expenditures under the National Health Accounts RH subaccount methodology, and this reporting seems to have occurred sporadically.14 The William and Flora Hewlett Foundation and Redstone Strategy Group estimated domestic developing country government spending in subSaharan Africa to be 19% of total support spent for family planning and reproductive health from all sources** between 1987 and 2006.15 If this is a true and representative glimpse at the overall picture, it is far less than what was promised in 1994. Given the magnitude of the resource tracking challenge, lack of overall spending data for developing countries is not surprising, but this leaves scholars to infer insufficient funding on the basis of poor reproductive health and family planning outcomes. During the same period, exponential increases in donor funding for sexually transmitted diseases2–4 helped achieve tremendous progress in the fight against HIV/AIDS16 – though those advocates now fear that funding will plateau at current levels.
increases for reproductive health and family planning in-country? Civil society’s crucial role in enabling people to claim their rights, in promoting rights-based approaches, in shaping development policies and partnerships, and in overseeing their implementation was affirmed by 164 governments in 2011.17 As Steven Teles and Mark Schmitt point out, “Very few big social changes happen without some form of advocacy. When these efforts succeed, the results can be transformative.”18 According to Dr Nafis Sadik, Special Adviser to the UN Secretary-General, the ICPD Programme of Action “secret of success” was wide consultation and active participation of civil society. As she puts it: “The physical presence of so many dedicated and committed people, many of them young, many of them women, meant that delegations were well informed about real-world concerns and priorities, and what it would take to make a real and lasting difference…”19 Many donor governments and philanthropists are now ramping up financial support for citizen voice and accountability work to strengthen national commitment to reproductive health and family planning in developing countries. For example:
•
Advocacy as a means to increase funding Considering the increased importance of domestic, developing country policy-making for resource allocation, how can international actors strengthen national advocacy to achieve sustainable funding *Liberia, 2007; Malawi, 2003, 2004 and 2005; and Rwanda, 2002. It’s not indicated why reporting exists for only these countries in only these years. †
To address this deficiency, the independent Expert Review Group on Information and Accountability for the UN Secretary General’s Commission on Women’s and Children’s Health recommended strengthening resource tracking, aiming for “at least 50 countries [to] use and have up-to-date and accurate data… by 2013.”11 If the target has been met, the data are not available online as of this writing (May 2014).12 Kenya actually produced poorer resource monitoring information after the target was agreed.13 **ODA, domestic governments, consumers, and HIV/AIDSrelated.
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•
•
In October 2013, the European Commission issued a €28 million global Call for Proposals for Non State Actors to improve universal access to reproductive health, with priority for proposals that, among other things support the implementation of public policy and capacity building designed to give better access to sexual and reproductive health; and strengthen local civil society organizations and local authorities. In 2013, the Ministries of Foreign Affairs of the Netherlands and Denmark, and the Packard Foundation, issued a Call for Proposals for a fund manager for a new “Civil Society Fund for Sexual and Reproductive Health and Rights”.20 In 2014, DFID issued a competitive Call for Proposals for a consortium of national civil society organizations, to be led most likely by an international NGO, to strengthen monitoring and accountability for family planning in up to 15 developing countries.21
This surge in donor funding comes from an evidence-based conviction that popular activism and civil society advocacy can effect changes in government policies and funding in specific contexts.22–27
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Theoretical models of advocacy effectiveness If civil society advocacy* can be effective, how can international advocacy strengthen national efforts to increase domestic political commitment and funding for all of ICPD? Wouldn’t it be wonderful to harmonize messages internationally in a way that would strengthen and support national advocacy efforts to increase funding? What insights can structured theoretical models of advocacy effectiveness provide? John W Kingdon argues that a window of opportunity opens when a problem gets policymakers’ attention (problem stream), when a clear way to address the problem is developed (policy stream) and when a political change enables the solution to be developed into government policy (political stream).28 The absence of one of these “streams” can explain why policy change does not happen. This elegant model works well in the national US context for which it was developed. In Washington, DC, most political actors work in relatively close cultural, physical and philosophical proximity to one another, where the underlying rules about how politics works are known (e.g. two-party politics) or learned on entrance to the system (e.g. who really wields power). Global advocacy has much more complex political dynamics. On the world stage, very few simple assumptions can be made about how the vast multitude of actors will respond to the cultural, political, economic and other incentives at play. Jeremy Shiffman proposed a concrete framework on determinants of political priority for global health initiatives that includes 14 factors falling into four major categories of influence in shaping political priority: actor power, ideas, political contexts and issue characteristics. 29 Shiffman’s 2007 tiered level-of-intervention analysis of how to generate political priority for maternal mortality reduction in five developing countries30 is impressive. It identifies and sorts what types of influence are most important at national and transnational levels to help structure global advocacy analysis, as follows:
•
transnational influence = norm promotion and resource provision
*Advocacy can be defined in many different ways. WHO provides a helpful working definition: “an organized, deliberate, systematic and strategic process intended to bring about a new or revised social or economic policy or programme.”23
• •
domestic advocacy concern = policy community cohesion, political entrepreneurship, credible indicators, focusing events and clear policy alternatives national political environment = political transitions and competing health priorities.
A recent wave of analyses underscores the dynamism of the complex matrix of advocacy variables that can have an impact. Many of these have their origins in Pawson and Tilley’s 1997 seminal work, Realistic Evaluation, 31 which observed that public policy programme implementation is embedded in social systems; that its effects require the active involvement of social system participants; and that programmes are open systems that cannot be kept constant or isolated from change in either external or internal factors. Teles and Schmitt argue that the very nature of advocacy itself undermines the usefulness of the sophisticated tools usually used to evaluate effectiveness. Among other reasons, they observe that: “The characteristic features of the terrain of politics – chaotic agenda setting, pervasive misinformation, overlapping responsibility – mean that no one metric can capture the reality of influence.”18 Despite its sophistication, Shiffman’s maternal mortality study on changes in political priorities in five countries from the mid-1990s until the early 2000s is itself compromised by such challenges. While the study was being conducted, the Paris Declaration and Accra Agenda for Action launched massive changes to the aid architecture “in relation to how much aid is provided, by whom, to which countries, through which modalities, as well as the purposes to which it is put.”32 With world social and political systems undergoing such rapid change, can large-scale, complex analyses of influence identify how forwardplanning in global advocacy can secure national support? How can any retrospective findings remain valid and relevant, considering the magnitude, complexity and speed of changes taking place in the national and international environment? How much influence and/or power remains with donor governments, how much with domestic developing country governments and how much with other influences altogether? Additional public policy research is required to examine possible answers. Narrowing advocacy assessment to specific advocacy efforts and/or to an advocacy organization’s 45
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“strategic capacity”18 provides a practical response to this complexity. David Devlin Foltz, 33 John Mayne,34 Barbara Klugman35 and others23 emphasize the importance of identifying the implicit theory of change being tested by the implementation of an advocacy project or campaign. They argue that data collection should include not just programme impacts or implementation processes, but also the specific aspects of programme context affecting results and mechanisms creating change. This enables scholars to identify and address the ways in which an advocacy effort has succeeded or failed to address factors that could not be identified prospectively. Keeping this in mind, Klugman35 prescribes seven change categories against which progress in social justice activism and advocacy can be assessed:
• • • • • • •
organizational capacity; breadth and capacity of the base of support for an issue; breadth and strength of alliances; the use of data and analysis; degree of coherence around a problem definition and potential policy options; advocates’ access to and influence in policy spaces; and visibility of the issue from the perspective of the advocates.35
This is a helpful model for assessing strategic capacity and the effectiveness of a particular advocacy effort. At the same time, this and related retrospective models leave a gulf between the assessment of a particular advocacy campaign, programme or organization in situ and the broader hope by international supporters of sexual and reproductive health and family planning that changes can be planned globally with plausible evidence for success in strengthening national political commitment. Reviewing the limitations and failures of advocacy in generating sustained funding increases may help point toward solutions.
When advocacy fails The following observations are based largely on my 27 years of practical experience with advocacy – toward the national and state governments of the United States, European governments and the European Union, and country decision-makers in Africa and Asia. Fortunately, 46
many others have had similar experiences, and where available, those observations are included. Policy advocacy does not change value-driven behaviour Advocacy that seeks to impose change not genuinely willed by the people to be affected (i.e. the public) will be of limited effectiveness and/or duration, as participants can always be expected to “game the system” in pursuit of their genuine interests. A great deal of concrete evidence demonstrates how pervasive social and cultural norms affect public policy priorities. Studies by Rose Oronje and others36–40 highlight the importance of social and cultural norms affecting grassroots political priorities and hindering development and implementation of effective sexual and reproductive health and rights policies across Africa. Oronje has shown “just how influential individuals in patriarchal societies can frame sexuality and women in ways that perpetuate and legitimize gender inequality and deny women opportunities to realize their human rights” even when policies are enacted in support of those rights.36,37 Freedman and Schaaf compellingly argue how advocacy that does not address real power structures is doomed to fail,41 and furthermore, that the globalized “best practices approach to implementation…requires evidence generated through studies with experimental designs that, almost by definition, require the nullification of exactly the power dynamics so central to understanding sexual and reproductive health and rights.” I suspect that many advocates around the world would silently or openly agree on both counts, but are trapped, deterred or defeated by the overwhelming momentum and power behind these obstacles. Non-binding international commitments do not drive national budgets Advocacy that focuses on generating international commitments or policies disconnected from legally binding funding mechanisms does not have sufficient power to effect sustained funding toward those commitments/policies. The ICPD Programme of Action is only one example of many international policy commitments whose concomitant national obligations remain unfulfilled by the very governments that signed them. Why? There may be advocates and decision-makers who genuinely believe that governments will naturally make a sustained effort
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to fulfill their commitments. Too often, though, the intensive surge of advocacy effort that goes into producing such non-binding commitments is followed by exhaustion among the campaigners who fought for the best possible declaration and by “thematic burnout” or complacency among political decision-makers who feel they have already done enough by endorsing a statement calling for desired change. Obtaining the funds to implement non-binding commitments requires a separate, additional, and often more difficult advocacy effort, through eternal cycles of budgetsetting by both donors and developing country national governments. Civil society capacity to meaningfully engage in budget advocacy is limited Civil society in many countries does not have sufficient knowledge or capacity to influence budget processes effectively. As observed by the International Budget Partnership (IBP): “Many civil society organizations, journalists, and even parliamentarians lack the basic skills to engage meaningfully with budget issues.” 42 This problem is further compounded by the limited capacity or willingness of many governments to assure the open, transparent, uncorrupt financial management required for democratic governance and accountability. As IBP puts it:
time-limited advocacy grant-giving. Nothing guarantees further momentum toward funding increases when the advocacy campaign or project comes to an end, and often, projects do not last long enough to be able to measure or monitor their real impact.23,27 This places both advocates and their donors in difficult positions. Advocates are forced into the uncomfortable position of trying to convince their donors to perpetually renew grant support in order to protect and sustain results, while at the same time trying to prove: (a) that they have already produced significant, sustainable results even if the debut grant wasn’t of sufficient duration to measure this properly; (b) that the timing of the renewal proposal is equally or even more urgent than before; and (c) that, even if they were already highly successful, something “innovative,” different or new in the methodology justifies grant renewal. On the donor side, these arguments may be difficult to buy. Even supportive donors who understand the need for sustained advocacy funding may find it difficult to convince their own stakeholders and accountability processes that anything should be funded repeatedly or indefinitely.
Unfortunately, capacity-building itself is cyclical: inevitable turnover of political representation and civil society organization staff requires regular renewal of capacity-building with new actors to avoid losing ground.
Advocacy success at national level does not help as decisions are increasingly decentralized to sub-national governments43,44 Decentralization seeks to reduce central influence and promote local autonomy. By changing who has authority and financial responsibility for health services, however, it can have a large impact on health system performance, bad as well as good.43,44 As pointed out above, national/ subnational resource tracking systems in very many countries remain insufficient for effective monitoring. 3,8–14 Similarly, national advocacy capacity rarely extends to the wide range of sub-national decision-making bodies empowered by decentralization, probably because many advocates and advocacy donors are overwhelmed by the information and resource burden required to do this well.
Even when budget increases are secured, annual budget cycles require perpetual advocacy for sustained improvements Civil society can impact funding when budget advocacy is implemented over a long period of time; however, most advocacy is dependent on donors who prefer or are required to provide
Budget advocacy and increases in funding do not assure improvements in outcomes Of course, even when funding increases, poorly spent funds do not improve health outcomes. As the Hewlett Foundation and Redstone Strategy Group report states: “Multiple factors, including donor policies (e.g. tied aid), actual activities
“…citizens have been traditionally excluded from budget decision-making and monitoring, as have been civil society organizations, legislatures, and the media…public budgeting is still conveniently governed by the arcane principle that budget information should be guarded as a state secret, and the process dominated exclusively by the executive. Budget transparency and accountability is often weakest in countries where poverty and inequality are highest.” 42
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funded, governance in recipient countries, and economic cycles can contribute to the success or failure of an investment and ultimate FPRH [ family planning and reproductive health] indicators.”15 Tracking the policy implementation process from budget setting, to disbursements, to programme implementation in the field is required to determine the obstacles to improving reproductive health and family planning outcomes when funding increases. Completing the IBP excerpt from above concisely illustrates this problem: “…The result is a massive leakage of scarce public resources into unnecessary projects, corruption, and ineffective service delivery, undermining efforts to reduce poverty, improve governance, and consolidate democracy.” 42
Three-pronged advocacy approach to achieve sustainable national funding Given the above, achieving sustainable, i.e. lasting, increases in ICPD and health funding at the domestic level argues for a new approach. The following three-pronged advocacy approach could enable international coordination of advocacy messages, while leaving the all-crucial contextualization to those at national level who are most directly affected by the problems to be addressed. 1. Local accountability is paramount Since the content of advocacy must be specifically contextualized for local needs and circumstances in order to gain support and be effective, one universal campaign theme might be ensuring that there are clear processes for democratic accountability at/to the grassroots level. One way to do this is through establishment of subnational community or citizen advisory councils to monitor local progress and push for improvements. Advisory panels in each local area, for example, could provide local authorities with information and recommendations from the community on the public’s reproductive health problems and needs. Regular meetings in each local area would allow residents to discuss pressing issues with decision-makers. Such meetings can also provide an opportunity for local officials to assess the impact of their policies on the community. Such councils are challenging to manage, and yet can produce tremendous value. In developing programmes to manage health systems in several US states, I found it very helpful to create distinct 48
advisory councils for consumers/beneficiaries, for health care providers and for government officials. Operating from the moment of programme design throughout ongoing operations, these advisory councils enabled participants to voice concerns and identify solutions. During policy/programme design, such input can help prevent a wide variety of problems, as seen uniquely from the perspective of each group. During start-up and early implementation, advisory councils can provide quick feedback if things aren’t going well, as well as a venue for managing expectations. During ongoing operations, they can ensure regular feedback to programme managers to inform policy/programme refinements and improvement ad infinitum. Having participants meet regularly with their peers creates a relatively safe space to air concerns, reducing the common power differentials that inhibit some individuals while allowing others to dominate. Disparate views coming from each council can be reconciled through sharing recommendations among them and bringing the councils together for concrete, joint problem-solving. The openness of recommendations can significantly help improve monitoring and accountability for building responsive programmes. An essay presented at the 2011 International Family Planning Conference in Dakar, Senegal, provided preliminary results on a similar type of work implemented in health in Africa. A consortium of non-governmental organizations sought to improve health budgets and policies, including reproductive health and family planning, by taking the following actions at the national and district level in 13 districts in Kenya, Tanzania and Uganda:
• • • •
increasing access to information on health and family planning budgets and policies; creating local civil society coalitions for greater voice; organizing education campaigns on civic rights and obligations, as well as the importance of family planning; and initiating dialogue at village, district and national levels to increase transparency in decision-making and allow poor segments of society to have a voice.
Reported results included strengthened advocacy; improved dialogue among community members, civil society organizations and local officials; increased transparency in local government decision-making; and apparent commitment
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to community accountability on reproductive health and family planning.43 The emphasis in both cases was local accountability. There are many examples of both genuine and pro forma civil society advisory bodies at the national level, such as those employed by national governments, donor delegations, or for example by the Global Fund for AIDS, Tuberculosis and Malaria for its Country Coordinating Mechanisms. National advisory bodies have their merits, but in order to operate effectively, their size must be constrained, which inevitably distorts the nature of the discussions. Genuinely local processes are key to translating discussions about policies and funding into results that are verifiably accountable to communities and individuals, regardless of what national party or government holds power. 2. National health programmes must be designed as legally binding entitlements Enacting binding national legislation that entitles people by virtue of financial and/or categorical eligibility to family planning, sexual and reproductive health care and other health benefits can be one highly effective way to circumvent annual budget cycles and bring about sustainable results. Provision of contraception is binding on the National Health Service in Great Britain, for example, and there are many other examples in the social protection mechanisms that currently exist in nearly all wealthy countries and many middle-income countries. In the US, Social Security and Medicare were themselves once unthinkable, but they continue to grow with the ageing of the population and provide minimal protection against poverty. Almost all wealthy countries have some form of social protection to which their citizens are entitled by virtue of their age, disability status, income level or other criteria. As poor countries develop, it is appropriate to ask them to do likewise, in accordance with the human rights imperative to take all feasible steps to respect, protect and fulfill the right to the highest attainable standard of health. Programmes with financial and/or categorical eligibility requirements would be exempt from annual budget authorization and approval processes, with programme funding determined by the number of people who are categorically eligible and the benefits to which they are entitled. Any funding needed to operate the programme which could not be met exclusively through
domestic government revenues in the poorest countries would require supplementation from donor governments.45 Models for how this might work need to be more fully explored. Would pairing national advocacy for legally binding eligibility programmes with international advocacy for a global Framework Convention for Health* or to Universal Health Coverage46,47 generate sustainable change? The devil, so to speak, is in the details, which both require and merit more study and prospective modelling. The usefulness of “legally binding” arrangements, of course, depends on at least two major contingencies. One of these is the effectiveness of the legal systems in question. There are arguably larger and more diverse constituencies around the world invested in improving legal system functioning than seem to be invested in improving sexual and reproductive health. Even if the constituencies supporting and benefiting from strengthened legal systems are not greater, per se, their efforts are largely complementary to the work of ICPD advocacy. Advocacy that successfully results in national legislation entitling people to sexual and reproductive health care could “leverage” the success of efforts to strengthen legal systems for improving sexual and reproductive health. Second, some professionals in the field rightly argue that right-wing political opposition to policies improving sexual and reproductive health mitigates the effectiveness of legally binding entitlement programmes, citing for example contraception and abortion coverage challenges in the US and a recent Swiss referendum to remove abortion from the list of state-reimbursed health services (which, however, failed by a wide margin). This second point leads to the crucial third leg of the proposed approach: the need for relentless, sustained work toward norm change in support of the right to health throughout the world. 3. Pro-health values and norms must be strengthened It has long been known that deep-seated cultural values and norms shape health outcomes, and further, that “religious” opposition to some aspects of sexual and reproductive health is often less clearly grounded in religious doctrine than in engrained habits of thought and practice. As *For more about the Framework Convention, see http://www. who.int/bulletin/volumes/91/10/12-114447.pdf.
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Oronje and others convincingly demonstrate,36–40 even when sexual and reproductive health have “official” support, efforts to improve outcomes can easily be undermined by individual or community values, through the choices people make and actions they take every day. For this reason, culture change – a critical mass shift in social norms – is needed to assure sustained change toward improved outcomes. Klugman observes “in the long term, to sustain policy victories, one needs to build public support for an issue”.35 Unfortunately, culture change and women’s empowerment are often neglected in the search for quick wins and immediate uptake. When neglected, community discourse on the norms and values that impede health – not least women’s power in their families and communities – will always lurk as an undermining factor. The sustainability of local and national civil society advocacy to improve policies and funding can only be strengthened by dogged determination to advance culture change, drawing on excellent resources in the field that already exist, such as the policy framework proposed by Knott et al to DFID in 2008.40
Conclusions The three-pronged approach described here could enable coordination of international advocacy messages in support of “local accountability” and “legal entitlement”, and leave the crucial contex-
tualization to those who are most directly affected by the problems to be addressed. Complementing Shiffman’s observation of norm change as a matter of transnational influence, these messages emphasize pro-health cultural norm change in communities as necessary to achieving lasting results, and address the increased importance of the national context for resource provision. Together, they could enable concrete mechanisms to systematically overcome common, cyclical obstacles and generate sustained results. In principle, they could bridge the gap between policy, funding, implementation and outcomes. Additional research would help identify ways in which aspects of this model have been tried and tested within the field of reproductive and sexual health; whether concrete case studies exist to verify or refute their promise; and enable forward planning to test the model’s underlying components. But even without additional research, as the post2015 landscape unfolds and policy-makers start narrowing options for international agreement, this three-fold approach merits consideration. Acknowledgements The author thanks Gorik Ooms for kicking off this analysis by asking questions, suggesting reading materials and patiently, substantively commenting on drafts; and Dirk Van Braeckel and the International Centre for Reproductive Health at Gent University for their support.
References 1. United Nations Population Fund. Programme of Action of the International Conference on Population and Development; 1994. 2. Deutsche Stiftung Weltbevolkerung and European Parliamentary Forum. Euromapping; 2013. 3. UNFPA. Financial Resource Flows for Population Activities in 2011; 2013. 4. United Nations Population Fund. CPD: The Flow of Financial-Resource for Assisting in the Implementation of the Programme of Action ICPD; 2010. 5. Organization for Economic Cooperation and Development. The Paris Declaration on Aid Effectiveness; 2005; and Accra Agenda for Action; 2008. 6. Deutsche Stiftung Weltbevolkerung. Fast Facts: SRH advocacy at the national level; 2009, 2011. 7. Deutsche Stiftung Weltbevolkerung. Fast Facts: Budget Support Consequences for SRH. Undated.
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Résumé Les engagements financiers que 179 nations ont souscrits en faveur des composantes de planification familiale et de santé génésique de la CIPD en 1994 n’ont dans l’ensemble pas été tenus. Alors que les donateurs accroissent leur soutien au plaidoyer de la société civile dans les pays en développement, dans l’espoir d’améliorer le financement et les résultats à l’échelon national, les récentes tendances dans l’évaluation du plaidoyer ne répondent pas à la question plus large de savoir si les campagnes internationales peuvent renforcer efficacement la prise de décision au niveau national et de quelle manière. Cet article informe sur les enjeux du suivi des contributions des pays en développement. Il résume les initiatives actuelles des donateurs pour consolider le plaidoyer de la société civile et analyse les approches théoriques à l’évaluation du plaidoyer. L’auteur identifie les principales limites du plaidoyer et propose une approche triple pour harmoniser les messages nationaux et internationaux pour des hausses accrues et soutenues du financement et des résultats en matière de santé, à savoir : la responsabilisation locale est primordiale ; les programmes nationaux de santé doivent être conçus comme des prestations garanties par la loi ; et les valeurs et normes en faveur de la santé doivent être consolidées.
Resumen En general, los compromisos financieros de 179 naciones relacionados con los componentes de planificación familiar y salud reproductiva de la CIPD en 1994 no se cumplieron. Mientras que los donantes incrementan su apoyo para promoción y defensa (advocacy) por parte de la sociedad civil en los países en desarrollo, con la esperanza de mejorar la financiación nacional y los resultados, las recientes tendencias en la evaluación del advocacy no contestan una interrogante general: si las campañas internacionales pueden fortalecer debida y eficazmente la toma de decisiones a nivel nacional y cómo pueden hacerlo. Este artículo expone los antecedentes relacionados con los retos de monitorear los aportes de los países en desarrollo; resume las iniciativas de donantes para fortalecer el advocacy por parte de la sociedad civil; y revisa estrategias teóricas para evaluar el advocacy. La autora identifica las principales limitaciones del advocacy y propone un enfoque de tres componentes para armonizar los mensajes internacionales y nacionales que abogan por mejores y continuos aumentos en la financiación del área de salud y sus resultados: es decir, que la responsabilidad local es primordial, que los programas nacionales de salud deben diseñarse como derechos jurídicamente vinculantes, y que los valores y normas pro salud deben fortalecerse.
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