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

1. Literature Review: Civil Society Engagement
to Strengthen National Health Systems to
End Preventable Child and Maternal Death
David Shanklin, MCSProgram/CORE Group
CORE Group Global Health Practitioner Conference
Portland, OR
Friday, May 20, 2016

2. Study Rationale
• The role of civil society in national health
system strengthening remains ill-defined.
• Disagreements continue to exist concerning
the roles and responsibilities of donors,
governments and civil society itself.
• The authors intended to identify the potential
of civil society engagement to strengthen
national health systems.

4. “Real development requires more than assistance and
aid. One of the things we’ve learned is you can’t skip
the governance component, and that’s been a painful
and important lesson.” Chris Beyrer, MD, MPH, JHU, BSPH
Secretary of State Clinton (2011) described legitimate “country
ownership”:
“To us, country ownership in health is the end state
where a nation’s efforts are led, implemented, and
eventually paid for by its government, communities,
civil society, and private sector…and those plans must
be carried out primarily by the country’s own
institutions, and then these groups must be able to
hold each other accountable…”

5. Methodology
• Iterative on-line search for public health
articles between the years of 2005 and 2015.
• More than 160 articles were identified.
• Articles reviewed based on relevance to this
search, and classified into four categories:
evidence (49), guidance (30), information (28),
and advocacy (1).
• In all, we referenced 108 articles for this
review.

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

7. Organization of Literature Review
Results are organized into three recurring
themes:
1. Roles of civil society and civil society
organizations
2. Key elements of successful civil society
engagement
3. Reported benefits of civil society engagement

8. Roles of civil society
and civil society organizations
There are eight basic roles of civil society
related to national health care systems:
1. Public information, advocacy and policy
development
2. Public oversight
3. Participatory governance
4. Direct service provision

9. Roles of civil society
and civil society organizations (Cont’d)
5. Capacity development
6. Resource mobilization
7. Research and innovation
8. Networking

10. Participatory Governance
• Also described as “social accountability”
• Many examples of tools and methods available
for: preparation and planning, involving
marginalized populations, identifying barriers
to participation, engaging civil society partners
with the government/public sector
• Public accountability and transparency, and
measuring outcomes

11. Key elements of
successful civil society engagement
Three domains of a framework for civil society
engagement in national health programming:
1. The national context, or the “enabling
environment”
2. Partner capacity, with a shared common
understanding of roles and responsibilities
3. Clear health need and available resources

13. USAID’s CSO Sustainability Index
• Highlights advances and setbacks in CSO
sector sustainability
• Allows for comparisons across countries and
sub-regions over time in 7 key components:
legal environment, organizational capacity,
financial viability, advocacy, service provision,
infrastructure, and public image

14. USAID’s CSO Sustainability Index (Cont’d)
• 2013 CSO Sustainability Index for sub-Saharan
Africa evaluated the CSO sector in 25
countries
• 10 of the 25 countries were in the
Sustainability Impeded category, the weakest
level.
• The other 15 countries remained in
Sustainability Evolving, the middle range of
CSO sustainability.

15. USAID’s CSO Sustainability Index (Cont’d)
• No country transitioned between 2012 and
2013, and no country reached Sustainability
Enhanced, the strongest level of CSO
sustainability, in any dimension.

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

17. Reported benefits
of civil society engagement (Cont’d)
3. Participatory governance introduced,
supported and capacity developed
4. Demand and use of health care increased and
improvements made to service quality
5. Health outcomes improved, including
increased service equity among marginalized
populations

18. Increased public awareness
• Heightened awareness of unmet health needs
• Importance of service quality to positive
outcomes
• Some evidence of shortfalls in CSO capacity
to monitor results, and contribute to longer-
term development outcomes

19. Increased funding for high priorities
• Strong evidence from HIV/AIDS: Civil society
engagement predated global funding
• CSOs engaged early in: HIV/AIDS de-
stigmatization, promoted prevention (such as
condom use and other messaging), and
energetically promoted increased funding
• Other examples: National advocacy for
directing financial resources to specific
priorities, such as maternal care; local
mobilization of resources for CB services

20. Participatory governance
• National/local CSO participation in health
planning and budgeting
• Use of checklists to monitor policy
implementation
• Improved transparency and monitoring
• Open and available data, and mechanisms for
regular discussion on findings

21. Participatory governance (Cont’d)
• Identify barriers to accessing services, such as
physical, economic, cultural, familial, and
transportation
• Organize priorities, develop and measure
indicators, and make suggestions for
improvements
• Frequently identified CSO capacity needs:
governance skills, measurement (M&E),
advocacy, and resource mobilization

22. Improved demand for quality health care
CSOs increase service demand and
improvements in health services in 3 ways:
1. Play a role in shared monitoring and oversight
2. Provide services directly in conjunction with a
national health system
3. Inform communities of improvements, and
mobilize public to seek timely health services

23. Improved program outcomes
• Increased public awareness regarding
treatment for common illnesses and diseases
• Increased timely use of services
• Decreased incidence and mortality
• Increased equity, serving hard-to-reach, at-risk,
and marginalized populations
• Greater involvement seems to improve
resource sustainability and infrastructure
quality

24. Limits of civil society effects
• More often achieved in an enabling context
• Not a replacement for weak national plans
• Community engagement has little impact on
outcomes when done in isolation
• Community engagement can substantially
amplify the impact of investments in public
health inputs

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

26. Conclusions (Cont’d)
3. Evidence suggests that the most successful
programs tend to be implemented with sub-
national governments that have some management
autonomy and are downwardly accountable.
4. When civil society is engaged in multiple ways,
in the context of a safe and enabling environment
(even if nascent), the evidence is strong for positive
health impacts.

27. For more information, please visit
www.mcsprogram.org
This presentation was made possible by the generous support of the American people through the
United States Agency for International Development (USAID), under the terms of the Cooperative
Agreement AID-OAA-A-14-00028. The contents are the responsibility of the authors and do not
necessarily reflect the views of USAID or the United States Government.
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28. Proposed model
for civil society engagement
Provides basis for MCSP program design in
selected countries and for concurrently developed
MCSP CSE Strategy.
Advances three outcomes:
1. Improve population health, demand and
outcomes, including lowered maternal, newborn
and child mortality rates, with increased health
equity.

29. Proposed model
for civil society engagement (Cont’d)
2. Develop and support social accountability
processes to inform both local and national
processes.
3. Build country ownership for health with shared
accountability through improved governance of
health involving government, civil society, and the
private sector.

31. Next Steps within MCSP/CORE Group
• Develop guide to current social accountability
tools and materials for adaptation in country
settings
• Promote the active engagement of
government and civil society through forums
to jointly address unmet RMNCH issues
• Malawi and Ethiopia appear to be prime
candidates for these applications

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