Under Pressure: Navigating the Politics of Health (Reflections from COPASAH Global Symposium 2019)

As civic space shrinks around the world, how can those working with marginalized communities navigate complex systems of power and exclusion?  This question was the subject of much debate at the first Global Symposium of The Community of Practice on Accountability and Social Action in Health (COPASAH), where practitioners, activists, community members and academics gathered to discuss issues of citizenship, governance and accountability in health.

IBP played a key role in the symposium, helping shape the framework as well as leading two sessions on strategic approaches to address challenges in fiscal governance and health.  To ground the conversation, IBP partners working on health issues from India (SATHI), Kenya (CEDC) and Nigeria (JDPC) – part of our Strengthening Public Accountability for Resources and Knowledge (SPARK) program – were able to add their real-world experiences.

IBP was also an active listener throughout the event; we identified the following key themes and takeaways:

Transforming the Politics of Accountability

Pre-symposium sessions focused on India, specifically:  Nikhil Dey and Aruna Roy (MKSS) and several other Indian activists and academics discussed the potential trajectory of social change processes as civic space closes not only in India but across the world.

The conversation emphasized citizen mobilization as a key driver of progress in India.  Particularly for marginalized groups, collective action has made problems visible and, in some cases, generated a meaningful response from the political system.  Additionally, the institutionalization of Right to Information, legal recourse, and public works programs like NREGA contribute to sustainable reform by creating pathways for citizens to advocate for rights and entitlements.

Beyond Citizenship

We must be careful about what we mean when we talk about “citizens” and “citizenship”. The concept of “citizenship” reinforces the entitlements of individuals, with regards to health and other social and economic rights.  This notion, however, excludes individuals and groups without pathways to claiming citizenship in any given state. Due to the often systematic denial of legal rights to stateless groups, there is a need to deepen global discussions on protecting the rights of these populations to health and other services.

Thinking and Working in (Eco)Systems

When thinking about the politics of accountability, we must be mindful of the systems that enable or inhibit its realization.  This is particularly true with respect to the intersection of service delivery and accountable governance, and even more so with the recent incursion of poorly regulated private sector providers in the delivery of health services, which has created an accountability vacuum in healthcare delivery.  An approach that looks more broadly at the accountability ecosystem and how it relates to health systems will allow reformers to identify and focus on actors, spaces, and mechanisms that can shift towards more inclusive practices.

Implications for Civil Society

There are no simple or direct ‘solutions’ to achieve accountability.  We must accept the realities of a longer journey of working to strengthen and democratize public finance, service delivery, accountability systems, and norms and discourses.  If systems function the way they do because of the current balance of power, then the shifting of power should be central to our approaches.  Building countervailing power through collective mobilizing, organizing, and engaging is an essential way of providing marginalized groups (and most citizens, more broadly) the political agency to influence decisions and ensure those with authority and power are held to account.  While civil society must root our work in people and communities, it needs to have an eye for building broad-based movements of actors across sectors and disciplines.

CSOs can play a role in bolstering and knitting together often disparate instances of collective action.  One example could be the bringing together of communities and front-line health service providers, who may share common challenges resulting from weaknesses and accountability gaps in the broader health system.  It is equally important to channel that action and engagement through strategic approaches.

The implication for CSOs is to fill the role of convener, connector and critical friend to citizens, civic actors and government reformers.  We must recognize that “measurable” changes – those that can be counted and put in a report – are ultimately not shifting the systems producing inequitable outcomes.

In addition, we must recognize that social accountability work requires enormous investments from those participating. Furthermore, individuals who work in these spaces may face harassment and abuse from powerful interests.  Civil society, organizers and practitioners need to incorporate this reality into their strategies and activities.

Learning by Doing (and Sharing)

There is a broader need for a learning agenda that helps untangle complex dynamics and unpack strategic options available to progressive reformers.  While the debate around the use of Randomized Control Trials in accountability spaces rages on, rigorous, participatory approaches can, if deployed more often, address our collective learning needs.  This is part of the agenda for SPARK, which is supporting action research work (in partnership with IDS Sussex and the Accountability Research Center).  Further, platforms like COPASAH can continue to provide space for sense-making and interpretation of evidence, experiences, and new ideas.

The Big Picture

As we move forward, we must be mindful of the temptation to celebrate quick-win reforms without also paying attention to whether the processes that deliver them are inclusive and participatory.  Amitabh Behar, the head of Oxfam India, cautioned that civil society shouldn’t abandon a focus on democracy as civic space shrinks and populist and authoritarian politics grow. We must continue to prioritize working – at the margins – to democratize spaces, strengthen accountability, and build citizen collective action, and strive toward the equitable outcomes we know are possible.


*All authors are staff at the International Budget Partnership:  Brendan Halloran is Head of Strategy & Learning; Samir Khan is a Program Officer with the Strategy & Learning team; Kenny Oleru is a Program Officer with the SPARK team in Nigeria; Mokeira Nyagaka is a Research Analyst & Trainer with IBP-Kenya.


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