Improving health sector governance through engagement and empowerment

This Practice Insight reviews and reflects on real-world examples of civil society organisation (CSO)b1dc748176b2 engagement in the health sector to improve service delivery and public procurement. The experiences of the Partnership for Transparency Fund (PTF) over the last 15 years in this field are examined to distil learnings and offer practicable ways forward for donors5b4fa789a58a supporting CSO activity.

There already is extensive literature providing examples of good practice and tools for health sector CSO monitoring.b5e7b00c3b5e Therefore, this Practice Insight focuses specifically on PTF’s experiences of how (or how not) to do it.

Over the past decades, there has been increasing acknowledgement that the inclusion of citizens and CSOs in health sector governance and anti-corruption measures can contribute positively to public service delivery.df2869a50877 The early days of civic engagement – marked by pre-packaged outsider ideas, training, and awareness raising – have given way to more inclusive activities that better respond to contextual needs, and facilitate voice, collaboration, and self-determination.9234dc291b76

Approaches that empower CSOs and communities to monitor public services and hold leaders accountable are typically founded on three hypotheses: 1) engaging those most impacted by corruption is the most effective way to tackle it; 2) civil society has a deep understanding of the socio-cultural and contextual nuances in which they are embedded, granting them legitimacy and public trust; and 3) employing bottom-up anti-corruption initiatives can circumvent corrupt state actors that hinder top-down integrity efforts.ea303d9e5e81 In addition, grassroots CSOs are quite often more cost-effective than consulting and commercial firms far removed from target communities.

There exists a common understanding of circumstances that contribute to successful CSO-led projects,68e90a0e6bf8 as well as those that lead to failure.4126f924cd16 However, as with other areas of development cooperation, while the outputs and intermediate outcomes of CSO monitoring can be discerned, it is difficult to accurately attribute impact of any single project or even the combined effect of CSO monitoring activities on population health outcomes due to other in-country or external forces operating in parallel.4543a27faa38

Within the health sector, CSO monitoring and engagement generally prioritises ensuring the delivery of available, accessible, affordable, equitable, and quality health services, and appropriate budgetary allocation.dc4b9e30e70c Guerzovich and Poli5633fd332e94 and Hutchinson et al.d0c14f3d93da suggest that CSO monitoring of service provision can pave the way for more advanced levels of engagement in health policy and health governance. These elements are aligned with PTF’s approach and the emerging paradigm shift that advocates embedding anti-corruption measures in health sector project design in a way that prioritises the overarching health system aim – the improvement of health outcomes (ie through improved service delivery) first, and the reduction of corruption second.e0b9101d0bc5 It is, therefore, important to consolidate learnings from initiatives that have applied such an approach in order to better understand the circumstantial criteria of CSO monitoring that contribute to improved health outcomes, as well as determine what approaches do and do not work in what contexts.

Methodology

This Practice Insight considers 15 PTF health-related projects implemented in seven countries between 2006 and 2020. The projects were funded through PTF internal funds and/or from external donors through competitive or direct funding mechanisms. Country selection for projects was guided by the requirements of donors and/or PTF geographic and thematic priorities. CSO partners were selected based on established relationships and networks when the funding source was PTF. Projects were designed and implemented in conjunction with and in response to the needs of the target communities, with support from PTF experts.fc3eb19d1f67

We reviewed relevant project documents and relied upon first-hand experience. Data collection was conducted in the form of semi-structured, qualitative interviews with 25 experts from both PTF (13) and the national/local partner CSOs (12) that were directly involved in the design, implementation, and evaluation of the projects. Interviews were carried out between July and September 2021. By definition this methodology focuses on insights from PTF work and sources, and as such carries with it bias embedded in PTF experiences. This risk has been addressed by triangulating PTF insights with other sources and studies, where possible.

Annex 2 lists all projects examined and their objectives. For more information on each project, please see the PTF project database and tools and other guidance on our publications page.

Learning lessons and identifying best practices from PTF’s experience

It is PTF’s policy to implement projects only when an assessment of the local context for project implementation indicates that CSO monitoring can plausibly yield positive results. Assessing context is complex.2673c6833da8 PTF partners assess whether the context is supportive, through an analysis of key contextual factors in the proposed project area such as: access to information; the willingness of authorities and other CSOs to engage; the technical and financial capacity of partners and other project stakeholders; and citizen willingness to participate in the development processes. In our experience, a lack of these conditions leads to negative outcomes, such as token participation, reprisals and denial of service, elite capture, violent state response, and community dissatisfaction. The country context matters for scaling up and sustainability. However, there are many situations where the local context may be supportive while country context is not. Context also changes over time.

Across the 15 projects reviewed, we consolidated the key lessons learned by identifying the success factors and challenges across four dimensions that are detailed throughout the rest of this section: partners – national/local CSO(s) that implement the project; community – those affected by the project; authorities – public sector officials and politicians involved; and projects – design and circumstances of activities. Lastly, we have also assessed and present preliminary lessons learned from CSO monitoring during the Covid-19 pandemic.

Finding the right partners

Combatting corruption is one of the most difficult tasks for civil society, especially when monitoring activities in the health sector. The technical capacity and resources required and especially the pushback from those being monitored are among the main challenges. Few CSOs specialise in the nexus of health and governance; in most cases, their focus is on one of the two topics.b18ca0c3f225 This is at least in part due to the high sector-specific asymmetries of power and information, as well as the complex requirements of data protection and ethics. An implementing CSO must, therefore, demonstrate capabilities and understanding to successfully carry out or oversee the activities required in monitoring projects and service delivery.721023ddeac9

Qualification: CSO staff have the capacities and resources required

CSOs must have the capacities required to conduct activities, namely human, technical, and financial resources. CSO monitoring activities are often characterised by a high and demanding workload with low rewards in terms of public attention or direct results attributable to the activities. Some health sector monitoring requires technical understanding and skills, eg clinical drug trails. When specialised skills are needed, finding the right CSO partner can be difficult. This is especially true in remote areas, poor and disadvantaged communities, or conflict states where talent is scarcer. However, this is not a constraint when the required skills are community awareness, mobilisation for collective action, constructive engagement, and feedback collection on access, equity, and satisfaction.

Depending on project scope and objectives, the skills required can range from basic, such as literacy, to advanced technical knowledge and facilitation skills for more demanding projects involving information technology or complex technical processes.

Furthermore, donor requirements – for example for financial management and reporting – can be a massive time and resource burden that may entail the need for separate skills and workload from CSOs in addition to project implementation.

Commitment: CSO is genuinely interested and committed

In PTF’s experience, a track record of community mobilisation, especially with consistent strong leadership, is a useful indicator that the organisation is committed to a topic. But the most effective organisations are embedded within target communities, understand them, and have strong networks/drive to bring about change within their communities. Several of our examples show that such CSOs can successfully implement health sector monitoring, sometimes even better than a CSO with a glowing track record driven by funding and donor agendas instead of genuine commitment to the project or community.

There are four common difficulties experienced by donors when identifying committed implementing partners.

First, the ‘usual suspects’ are typically organisations that are easily identified, interested, and competent.20fdab7c696b However, they are also the ones most sought after and run several concurrent projects – a practice derogatorily coined as ‘donor hopping’. There is a risk that this limits the resources, time, and interest an organisation may be able or willing to dedicate to the project. Throughout our projects, PTF has been successful in identifying CSOs genuinely committed to the target community and the project objectives. We attribute this to the use of a vetting process that relies on our experts and their networks who have decades of experience working in international agencies. Furthermore, we invest in personal relationships between PTF experts and the partner CSO, in addition to technical review and formal due diligence of project proposals.e1c8bef0bc8d

Second, there are risks for conflicts of interest or even misconduct by implementing partners, especially for monitoring projects in the health sector. In addition to power and information asymmetries and lack of transparency, service delivery is characterised by a high degree of confidentiality, and procurement involves large amounts of money and strong interests. Throughout the projects we reviewed, only one such case was reported. In the project with NAMFREL in the Philippines, a volunteer monitor had an apparent conflict of interest due to relations with a private company. NAMFREL has a protocol prohibiting such conflicts for volunteers. The incident was identified early, handled transparently, and the person was removed from the project before causing harm.4a6172f2f9fd

Third, CSO monitoring frequently causes resistance and pushback from those under scrutiny – even when conceived in a cooperative manner, as the example below details. It is important for CSOs to understand the risks involved and be prepared to accept them or design the project differently to circumvent them, or be able to work in the face of resistance. In PTF’s experience, these difficulties can be minimised by following good constructive practices, such as engaging with authorities right from the beginning and, when possible, entering into a memorandum of understanding.bcb988399a33

Fourth, experience has shown that engaging CSOs in activities outside their comfort zone or areas of interest can work up to a point when accompanied by appropriate technical assistance. However, it is not recommended where it may overwhelm or divert from core objectives or the most pressing needs of communities. Donors need to avoid ‘mission creep’, whereby financially dependent CSOs must forego their own objectives in favour of donor priorities. Implementing partners best know the local situation, their own competency, and their preferred approach. We have learned the value of spending time and effort on truly understanding our partners. This is not limited to their technical capacities but includes their underlying motivation and values.7f68a49b13ce

Embeddedness: CSO has trust, support, and convening power in the community

The delivery of health services directly and strongly affects people’s well-being. The objective of monitoring activities is ultimately to attribute accountability, which can create contention among service providers. CSOs must therefore enjoy high levels of trust from beneficiaries, and strive to achieve the same with service providers or procuring agents. Building trust requires time and continuous support, and tailoring the monitoring ambitions accordingly.

In addition to long-term support, engaging in topics that are important to the community (see Boxes 4 and 5) is particularly conducive to building trust.

Depending on the context, objectives, activities, and tools applied, the specific requirements to rally trust, support, and convening power can differ significantly. It is therefore important to understand these parameters and design projects accordingly. For example, our projects that aimed to increase vaccine equity were focused on facilitating and monitoring compliance for priority groups, such as the elderly. Most challenging are those approaches – like our projects that concentrated on monitoring integrity in procurement and contract management – that aim at using monitoring results to confront public agents, for instance in the form of a public hearing. Here, success depends on the convening power of the CSO and its capacity and clout to control such meetings, as well as the cooperation of the different stakeholders involved (see Box 3). In the best of cases, these approaches can result in the institutionalisation of new structures, as the following example shows.

Clout: Choosing a partner – local vs national CSOs

Donors can implement projects either directly with CSOs or through a partner organisation at the national or international level who then, in turn, has local subsidiaries or implementing partners. Both approaches have their advantages and the choice is driven by project objectives. While working with the local partner provides a direct relationship with project staff on the ground, their capacities are usually lower. They tend to have less access to governing structures or political clout at higher levels and lack the capacity to scale up projects outside their community. Conversely, national level CSOs may have more capable staff and experience, as well as more influence on the national level, but are less connected to communities; instead they gain access by going through local partners. Across the projects reviewed, both challenges were observed: the need for more local presence but also for stronger clout at higher levels to drive implementation on the ground. The lesson we draw is to consider the project requirements and implications for the partner organisation.

Trust: Long-term partnerships with CSOs are an asset

A consistent theme throughout our project evaluations was the challenge for donors and PTF to keep abreast of the reality and challenges on the ground, including assessments of implementation and success.

This is especially true in cases where donors have no in-country presence, activities are conducted in remote locations, and for small projects where (international) travel for field visits would consume a significant proportion of the project budget. Despite these constraints, PTF was able to engage independent evaluators who visited project sites and partners.

PTF considers long-term partnerships with competent and trusted local CSOs a crucial asset worth investing in for solid results. Accordingly, it maintains long-term funding and repeated cooperation in different projects with the same CSOs. Examples include Youth for Social Development (YSD) in India and ACCU in Uganda, where PTF has supported them for more than a decade.

Engaging the community

CSO monitoring projects involve a group of people (the community) that can be defined as the population of a certain area (eg a village) or a group with shared interests, such as those affected by the project, like women, youth, or a patient group.8cf499090c44 The community is contrasted with duty bearers (eg health service providers).

For interventions to be successful, the community should have certain characteristics. Its members must identify with the problem to be addressed, have a desire to change it, and be willing, capable, and empowered to engage in a way that the activities and tools require. PTF projects are conceptualised in response to the problems and challenges facing communities. Marginalised and vulnerable groups, such as women and girls, are included in most projects as integral members of a community, and explicitly when they are the intended beneficiaries. In our experience, health sector interventions generally target more women and girls, who on average engage more frequently with the sector compared to men and boys.8a81f7650c27 However, aside from these considerations, PTF has not explicitly included additional dimensions with respect to gender or vulnerable groups in the projects assessed.

Enabling environment: Supportive cultural norms and legal, regulatory, and institutional frameworks

As a general precondition, citizens must have the rights and means to conduct project activities, such as freedom of expression and the right of association.c94d10d4b7a6 Information must be available in an adequate, useable form, and at the appropriate time – for example, through right to information laws or electronic procurement platforms that allow for effective monitoring. Additionally, community activities must consider cultural norms of engagement – for example, regarding the socio-cultural acceptance of whistleblowing or the role of women in public events.

Priority: The project addresses a key problem

A project should deal with an issue that is important to the community. The more directly their own livelihoods and well-being are affected, the greater their desire will be to address it.

The timing of an intervention is important, as it influences the urgency of an issue. Illustrative examples include our Covid-19 emergency relief projects.

Communities will feel the effects of poor public service delivery more directly than centralised or higher-level problems, such as inefficient procurement. It is therefore easier to mobilise them for projects related to monitoring in this area.

However, the negative consequences of corrupt or inefficient procurement can be stressed and brought to the attention of beneficiaries, to illustrate how these less obvious problems indirectly affect them. Access to publicly provided or affordable medicines for a widespread, severe disease is more relevant than transparent procurement and warehousing of pharmaceuticals. In such cases, smart framing will help capture community attention and buy-in.

Many interviewees highlighted that through continuous civic engagement in a community, issues begin to arise which may not be part of an ongoing project, but that matter greatly. Understanding the concerns of the people and building on this knowledge by addressing them has been singled out as an important success factor, as it establishes trust with and support from the community.

Additionally, media and publicity campaigns – if they are done well – are powerful tools often used to mobilise support as they ‘raise awareness and keep duty bearers on the edge of their seat’ (Jeff Kass, PTF).

In summary, identifying and prioritising community interest is the foundation for successfully engaging the community. This key precondition is generally outside a project’s sphere of influence when a donor has defined the focus of the interventions. This does not present a problem when community and donor interests align; however, failures can occur when they do not. For monitoring projects, convergence can be achieved through awareness and information campaigns to ensure the community understands the basis of the problem and sees value in monitoring activities.

Participation: Individuals are willing and capable to fulfil their role in the project

Depending on the activities and tools applied, participants need to be able to play their part. For example, monitoring under usual budget conditions requires large amounts of volunteer time. This often calls for a balancing act on the part of a CSO. People will volunteer up to a point if they see potential benefit. Beyond that, they have to see tangible benefits. This reinforces the need to monitor responsiveness by authorities and close the feedback loop.

Securing the buy-in of authorities

Civil society monitoring affects those in positions of authority (ie duty bearers), such as local political leaders, who have advantages of power and information over the community they are meant to serve (ie services users). PTF aims to avoid the confrontation that can arise when trying to force authorities to adhere to rules, regulations, laws, or the will of the community. Instead, our preferred approach is constructive engagement by partnering with relevant authorities who are in a position to effectively support monitoring activities and ensure findings lead to sanctions or changes to the system. Such relationships can be governed by formal agreements, like memoranda of understanding, or through the direct involvement of authorities in project activities. Alternatively, collaboration with authorities can be of an informal nature through personal networks and based on voluntary cooperation. Sometimes our partners must mobilise community collective actions to put pressure on local authorities to respond to community concerns and needs.

Official support: Relevant leadership promotes the project on a continual basis

Political support is required at the appropriate level of a context’s hierarchy. In many countries, local politicians have direct influence on local institutions, their leverage is much weaker at the central level, and vice versa. It is, therefore, vital to gather support at the appropriate level(s) required for achieving project objectives. The good news is that politicians are not monolithic and their interests vary. Often CSOs are able to find champions who support reform projects. However, these champions can come and go. So, while CSOs should identify champions, they are also advised to maintain vigilance.

The challenge is for CSOs to maintain support and interest when circumstances change because of factors like new topics arising on the political agenda, frequent changes in personnel and elected officials, or interference by powerful individuals opposed to increased accountability. In PTF’s experience there are good and bad examples of local authority support and it can change over time, even during the same project (see Box 6).

At least one other project reviewed (Heartfile in Pakistan – see Box 11) was affected in a similar way through the sudden loss of seemingly strong support. These experiences offer three lessons to be learned. First, relying on a single source of support is risky, especially in cases of elected officials, as their position can change quickly.

Second, the risk of losing reform champions emphasises the need for flexible and adaptable project design and implementation. This includes opportunistic implementation; getting things done while political support is strong; and, conversely, being prepared to exit a project prematurely if the context becomes prohibitive. In some contexts, collective action by the community (including the media) can pressure authorities to be more responsive than they would be inclined in the absence of it.

Third, long-term engagement and continued cooperation with partners embedded in the community are the only way of mitigating – albeit not eliminating – the risks of changing circumstances.

Another vital source of support can come from progressive bureaucrats at different levels and institutions who may be motivated by service orientation, career advancement, and demand-side pressures from community and/or the media, and have a pioneering spirit. Their support is needed for access to functions, staff, and information, as well as the handling of requests and grievances that are vital for the success of any project. In our experience, it is necessary to create incentives and/or public pressure where context permits, to garner such support.

The key takeaway is that there is no one-size-fits-all solution and our partners used a combination of approaches (reform champions, constructive engagement, collective pressure, and use of the media) to generate positive responses from authorities to issues and solutions emerging from monitoring. In most cases they succeeded but in some cases the project had to be discontinued.

Health sector buy-in: Medical staff, administration, and regulators participate actively

Health sector professionals are a critical stakeholder group, as they are responsible for much of the activities that are being monitored, such as service delivery, medical procurement, administration of infrastructure, and oversight of the health workforce. It is a naturally challenging task to engage public institutions and staff in activities related to outside monitoring; it requires trust and confidence building, which takes time and effort.

Ensuring accountability is the responsibility of structures within the system, either on an institutional level (eg compliance programmes, internal audit) or via oversight by central independent watchdog organisations (eg auditor general, comptroller general, parliament). CSO monitoring activities are a complement to these structures, especially where they are not functioning well, but they cannot replace them.fb06ff6adbaa PTF advises its CSO partners to bring all cases of corruption to the attention of relevant authorities, including auditors and anti-corruption agencies.

Engaging and partnering with public service implementation and accountability institutions is a vital component for two reasons. First, they can provide access to required information, which can serve their interests. Such engagement can help to dispel the notion that CSOs are only there to criticise.

Second, cases and issues identified must feed into accountability structures and lead to consequences, otherwise the value of monitoring is constrained and can contribute to complacency or weariness in communities.261c229df1e4

Engagement with public institutions can be done on different levels of the system. As they have varying roles to play, it depends on project requirements: partnerships at the local political level and at lower to medium levels of health system institutions allow for direct access to facilities, structures, and relevant information and processes to carry out monitoring activities. Partners at the central level and higher up in hierarchies can provide support and pressure to enact changes or measures at the local level or to policies, regulations, or even laws. Our experience provides mixed results. In the Philippines, reliance on national authorities proved to be risky, while in Nepal it was needed to increase responsiveness at the local level (see Box 8).

One takeaway from these and other PTF experiences is that efforts to enlist official support for constructive engagement should be directed at both local level officials closest to service delivery points, as well as at their supervisors. This is important not only for increasing responsiveness but also because in many situations, local authority willingness and capacity to act is influenced by the views and support of their supervisors. Another takeaway is that in many instances, monitoring can lead to positive changes in the behaviour and responsiveness of authorities without consequences for their past corrupt behaviour. The latter depends on the effectiveness of accountability institutions and processes that usually take a long time to impose consequences, if at all. Most projects are over by then.

Project design and implementation

The qualities of communities, partners, and authorities are generally pre-determined in a given situation. Sometimes PTF can choose situations to work in, while other times we cannot. In any situation, project design must fit the context and objectives. This is critical as, even in comparable environments, the same approach can have vastly different outcomes.ff4aa017d7b3

PTF’s approach: Constructive engagement

CSO monitoring can be conceived as applying a rights-based approach that focuses on identifying beneficiary entitlements and provider obligations (eg healthcare services and their administration). Project objectives aim to hold the public sector accountable and demand compliance with rules, regulations, and laws to provide beneficiary entitlements.

As mentioned above, our approach of constructive engagement is non-confrontational and based on engaging and cooperating with authorities.109e50da15f9

Achieving accountability without confrontation is a challenge that requires sensitivity, and understanding of the situation and those involved, to find the right balance.

A less aggressive approach often requires patience and tact.

Strategy: Project design meets objectives under local circumstances

We identify four factors relevant for project design, described below. These include, objectives, planning, entry point and alignment with priorities, and flexibility.

Objectives: We see three different types of objectives for CSO engagement with varying levels of requirements:

• Awareness: Engage to empower community members to understand and advocate for their rights and entitlements
• Accountability: Engage to ensure accountability (clean procurement, better service delivery)
• Systemic changes: Engage to change the system (policies, rules, regulations, laws)

The 15 projects reviewed all raise awareness among beneficiaries, and increase authorities’ responsiveness and accountability. It is noteworthy that, in several projects, objectives related to systemic change were not achieved. This limitation emanates from the small grants (typically under US$50,000) and grassroots characteristics of PTF projects. The focus in such projects is to make a difference during the lives of target beneficiaries, through social accountability approaches that foster corruption-free and responsive service delivery during the project period. Systemic changes require research, advocacy, legal, and regulatory skills, as well as sustained and adequate funding levels.

Planning: At the beginning of strategy design, a context analysis must be carried out to understand the community, as well as the political and institutional environment, in sufficient depth. The methodology, type of data, as well as need for anonymity of respondents should be commensurate to the context and requirements of the project. Quantitative information is necessary to establish a baseline for evaluating later impact, and exploration via qualitative data can guide project implementation.

Entry point and alignment with priorities: CSO monitoring should not be a standalone activity.77d05b684f9c Rather, it requiresan entry point and alignment with the sectoral context, including existing frameworks, priorities, and activities – such as international commitments like the SDGs, national or sectoral strategies, or ongoing movements or campaigns. Using such frameworks and their respective indicators for grassroots activities, where appropriate, can help align bottom-up and top-down approaches.

Flexibility: It must be feasible to adapt the project to changes in circumstance. Potential contingencies should be considered – in the worst case including the option to terminate a project, if necessary. PTF has exercised this option in several cases; doing so in a transparent manner is an important lesson for all donors.

Monitoring, evaluation, and learning: The basis for understanding success or failure

A strong monitoring, evaluation, and learning (MEL) framework based on a programme logic, or theory of change and suitable indicators with appropriate baseline data, can be an administrative burden, especially for small, local CSOs. However, our experience indicates MEL is a key element of successful projects and programming. It allows managers to ensure activities are on track (monitoring) and make changes as necessary throughout the project cycle. It is the basis for assessing and attributing results, and ultimately understanding the project’s impact (evaluation), as well as learning so as to improve future project design and implementation.

MEL is generally weak in many anti-corruption projects and institutions. Inherent problems like the lack of data, the difficulties of measuring corruption and anti-corruption efforts, and attributing success to project activities make it a particular challenge.

In many CSO projects, monitoring is hampered by a lack of suitable indicators, or a focus on process indicators. And if they exist, indicators are often ignored, as implementation is considered more important or there is neither time nor budget available.b705c8fb42ca

Evaluation is often hampered by missing baseline data and poor documentation due to a lack of either the skills by local staff or of time and budget for such activities. It is also difficult to conduct an honest and objective review that focuses on actual lessons learned rather than exclusively on the positive aspects, as this may negatively impact future funding.

Given the small size of many PTF projects, formal external evaluations are often not feasible as they would take up a significant proportion of the budget. We acknowledge that there is room for improvement in understanding our work through objective evaluation and feedback. PTF and donors in general should: (a) develop standardised frameworks that include indicators that can be applied, selectively adapted to projects, and aggregated across a portfolio – without reinventing the wheel in each case; and (b) seek expert advice to see whether randomised control trial methodology can be incorporated in project MEL design and budget.

Tools: Interventions are suitable for context and match the capacity of those implementing them

Appropriate and easy-to-use tools facilitate successful CSO monitoring activities.aa077a5bf22c Two aspects are important for their selection in a project.

First, the usefulness of a certain tool is highly contextual; community scorecards or health committees, for example, have been shown to work well in certain contexts but not in others.6edba8684453

Second, tools must match the capacity of those implementing them. For instance, our experience with CSO-led events that bring together the demand (service users) and supply (duty bearers) sides in the form of public hearings or public accountability forums illustrates both aspects (see Box 3).

Multi-stakeholder events can yield great results when conducted correctly and participants are cooperating. This was the case in most of the projects reviewed. However, there are cases where such activities end in confrontation rather than constructive engagement, leading to a deterioration of the situation and relationships.

This illustrates that confrontations need to be planned carefully, anticipating potential risks, and moderated professionally. To maintain a positive, long-term relationship and engage constructively, both parties should be present, adequately prepared, and willing to present their position. Local CSOs organising such events have no effective control over either party; de-escalation may not be possible. In this context, it is important to note that while community members must be empowered to claim their rights, they cannot be controlled and may cause problems – as the above example from Uganda demonstrates.

Whistleblower hotlines or complaint mechanisms are further tools. These interventions require high technical competence to maintain the confidentiality of records, while at the same time communicating with the reporting parties. Also, those reporting must have trust in the channels; this requires the reporting mechanisms to be appropriate and accessible to all beneficiaries. Our experience in Uganda (see Box 12) shows that especially with the application of tech-based solutions and tools, both the local CSO, as well as the donor, need to have the capacity and knowledge required to design and implement them. In this case, the development of a centrally located, technical solution that depended on a local organisation to receive calls, and collect and forward information, revealed unforeseen technical challenges that impacted project results. ‘With technology, you can’t fake it. You need real experience.’ (Frank McNerney, PTF).

Sustainability: Continuity of achievements remains a major challenge

The outcomes and impact generated during the life of the project are important, and ideally should remain as permanent improvements after it has ended. This sustainability aspect is among the biggest challenges for anti-corruption work in the health sector.

Prior research has identified factors that facilitate sustainability, such as visible improvements, effective use of social accountability tools and local structures, a support network and leadership, officials committed to service and integrity, and community financial contribution mechanisms.60d66b371847 However, there are no common guidelines on how to achieve sustainability.

Flexibility and opportunism during implementation are also important,5f0693f0c3c1 as confirmed by our experience. Even if certain project components fail, others can still succeed. While circumstances are opportune, and taking into account any changes required, the project team can focus on the successful parts and work to replicate and expand on them.34fef1382845

The challenge varies significantly depending on what objective is followed (awareness, accountability, or responsiveness). On the one hand, awareness-raising achievements are comparatively easy to realise and maintain.

On the other hand, maintaining improvements achieved through accountability-related activities is particularly difficult, as those benefiting from corruption will try to get rid of them after the project has ended. Therefore, mechanisms of monitoring and accountability require constant vigilance and may face permanent resistance from those being monitored or held accountable. Institutional sustainability is needed to safeguard improvements. Frequent turnover in elected and appointed positions makes this difficult to achieve and maintain.

Additionally, experts consider short time horizons a major challenge. Lack of planning and a budget for the phasing out stage are common problems, especially for projects with short durations.

An important contributor to achieving sustainability is that the implementing CSO understands its role as facilitator, linking the demand side and the supply side.3095e84c789d CSOs as catalysts for positive change should not be the agents that bring about such change.

This is especially crucial for monitoring activities, as CSOs need to achieve a high degree of empowerment to successfully ensure accountability while at the same time maintaining the role of facilitators. Furthermore, financial sustainability is an ambitious goal for monitoring activities, as they require permanent funding or voluntary engagement.

A very successful case was the Covid-19 response radio programme in Ghana (see Box 5). Such an activity would normally require an estimated budget of around US$ 20,000. Due to the high interest in the topic and its great success, the radio station took on the production costs, and the programme is still running today.f56e85abacb1

Lastly, our review raises the question whether achieving sustained change must always be the ultimate objective. Projects with small budgets and short time horizons may simply not be suitable for achieving long-term sustained change. Therefore, a project purpose could instead be defined as investing into a relationship with a partner or simply a contributory step along the way to a more substantive outcome.

Alternatively, small project success can be defined through outputs when the context is suitable, such as in most of the Covid-19 emergency relief projects discussed in the next section.

CSO monitoring during Covid-19

Consequences: The effects of the pandemic on monitoring

The Covid-19 pandemic has profoundly affected the health sector in general, and CSO monitoring activities specifically. We identify that the pandemic affects CSO monitoring in two ways: 1) it fundamentally changes or interrupts ongoing projects; and 2) it rapidly introduces a large number of new projects. Some of the major challenges facing CSOs include changes in the level of executive power held by leaders; governments abandoning standard procedures for emergency protocols; restriction of movement, social distancing regulations, and risk of infection during CSO field engagements; greater difficulty in accessing information for monitoring activities; high cost of Internet and online services; problems in establishing/ maintaining momentum for civic activities; and shrinking civic space.8d36e937a428 Furthermore, there are challenges in connecting marginalised communities to emergency social protection mechanisms.

But, with the influx of unprecedented amounts of funding to support health systems and buttress economies, the need for bottom-up accountability and monitoring is greater than ever to ensure funds reach their intended destinations.

Solutions: Creating frameworks to aupport the global response

In early 2020, we had finalised most of our non-Covid-19 projects. Thus, a review of them offered no insights as to the effects of the pandemic on project activity, other than the confirmation that diligent planning should include provisions for force majeure.

However, since the pandemic began, PTF has formulated a framework for CSO engagement in Covid-19 emergency response projectsf3e809d9555d followed by a framework to enhance equity and good governance in vaccine deployment.1a0283037730 These documents include the following activities that CSOs may adapt for their local context:

• Promote community demand and registration for, and access to, vaccination
• Monitor equity, quality, and efficiency in vaccine service delivery at vaccination sites
• Monitor national vaccine deployment plan (NDVP) transparency and communications efficacy at national and local levels
• Engage constructively and advocate with government authorities and donors to improve responsiveness and implementation of NDVPs
• Share knowledge and lessons learned, in-country and beyond

In line with these frameworks, PTF has supported CSO engagement for Covid-19 response in five countries (India, Ghana, Zambia, Uganda, and Argentina), and contributed to knowledge sharing.a13f131879d9 Key interventions being supported are shown below:

A summary of our activities and experiences so far is provided below.

Raising awareness. The scope included: general information; Covid-appropriate behaviour (mask wearing, social distancing); access to diagnostics, vaccination, and treatment; procurement contract award announcements; distribution of supplies and equipment; and funding and allocations. CSOs used a variety of media – truck mounted megaphones (Ghana), local radio programmes (Ghana), help desks (India), awareness camps (India), data validation meetings (Ghana), community education at health centres (Uganda), social media campaigns (Uganda, India), and local media announcements (all countries). These activities are generally welcomed by governments. Key challenges related to receiving timely and accurate information from reliable sources, worker safety, procurement difficulties, and travel restrictions during lockdown. Some workers became ill and had to be quarantined.

Household surveys. This is underway in India, Ghana, and Uganda to identify people’s views and experiences with vaccination, misinformation and demand-side barriers, and satisfaction with Covid-19 interventions and grievance redress. Findings will be used to help increase vaccine uptake and inform awareness-raising efforts. Challenges include fears of data misuse, particularly by the vaccine hesitant. Trust in the CSO is helping overcome this.

Access to services and vaccine uptake. PTF is aiding marginalised and vulnerable groups to access benefits and services (including vaccination) offered through government pandemic responses.Partners in India, Ghana, and Uganda are mapping marginalised (such as women and children) and vulnerable (those with morbidities or mobility impairment) populations. In India, this includes establishing community help desks, door-to-door canvassing, and providing transportation. In Uganda, citizen report card findings are being used to enhance government responsiveness. In Ghana, partners are working with local media to raise awareness of entitlements and engaging with duty bearers to share beneficiary feedback. Partners reported tens of thousands being aided to get vaccinated. The challenges relate to availability of information and vaccines, and duty bearer readiness to engage with citizens.

Third party monitoring to enhance transparency and accountability. Monitoring activities by partners are focused on delivery of services, procurement integrity and distribution, and public expenditures.

• Vaccination services. Our partners are developing checklists to observe vaccine centre compliance with vaccination protocols. Data will be shared with local and higher-level authorities to close implementation and supply gaps. The key challenges relate to authorities’ cooperation and the technical capacity limitations of CSOs.
• Acquisition and distribution of critical medical commodities. Our partner in Argentina is using checklists and observatory data to monitor medical procurement and distribution. The project includes an initial phase of engaging important allies such as the General Audit Office, CSOs involved in anti-corruption work, and a network of journalists. Authorities have supported activities through greater disclosure of information, albeit still short of requisite levels. Phase II is ongoing.
• Covid-19 donation tracking. Our partner in Zambia is establishing a dashboard to track Covid-19 donations and disbursements, and gather community feedback. Journalists will be trained on the system and supported to follow up on undeclared Covid-19 donations. A steering committee has been established to secure cooperation, and government departments are being engaged through meetings; a memorandum of understanding is under discussion. Challenges so far relate to disruptions and delays caused by elections and staff testing positive for Covid-19.

Collaborating with the media. All partners attach a lot of importance to working with the media to disseminate results of their assistance to communities and to monitor the Covid-19 response. Journalists are vital participants in our projects. The key challenge is the level of media freedom. So far, partners in all five countries have been able to conduct operations without government interference.

Constructive engagement with government authorities. Experience so far is mixed.Our partners have been able to establish good cooperation with national and local level authorities for activities that involve addressing demand-side barriers to vaccination, complementing public communications and emergency relief. CSOs are establishing close working relationships with frontline health workers. But cooperation has been ambivalent for accountability activities through monitoring and public reporting. Partners have just begun monitoring equity and good governance in Covid-19 vaccination and plan to constructively engage with local authorities to improve service delivery responsiveness.

Challenges and limitations

This Practice Insight has described the key learnings to be drawn from PTF projects. Some projects failed, some achieved modest results, but most were found to be successful by independent evaluators. This gives us confidence that PTF’s approach is on the right track. However, replicating and scaling PTF’s approach requires identifying and overcoming limitations. These include:

Scalability

The successful scalability of PTF projects is a common concern raised by donors. As a niche organisation, PTF attempts to rally the vast expertise of its cadre of international experts, who are predominantly volunteers, and apply global best practices through local partners. This approach builds the capacities of local CSOs that are ‘up and coming’, which we identify as a significant strength and unique offer. However, the model limits chances for sustained follow-on funding as it has to date not been able to demonstrate PTF’s capacity to manage long-term, large programmes. This needs to be held in balance, as a large increase in funding could dramatically deviate PTF from its strengths in supporting local capacity building and grassroots-driven project design – ie the very nature of PTF as an organisation.

Lack of PTF in-country presence

Not having an in-country presence is a deliberate part of the PTF approach for reasons of cost effectiveness and providing room for local capacity to develop. However, in health projects this was commonly mentioned as a core challenge. Having people on the ground is essential. PTF currently is pursuing a two-fold strategy to address this challenge by: (a) giving priority to countries where we have resident advisers that can develop country strategies, foster and sustain local relationships, and conduct site visits; and (b) building on established and trusted partnerships with national CSOs to fulfil these functions on PTF’s behalf. This latter approach increases local ‘ownership’ and bodes well for long-term sustainability and scalability.

Lack of accessible and sustainable funding

A lack of sustainable funding is a major limitation for scaling up successful projects, institutionalising systemic changes, and building local CSO capacity. Donor financing to carry out anti-corruption activities or establish anti-corruption regimes in programming in the health sector is negligible relative to overall health sector expenditures – as saving human life and improving health outcomes generally take precedence. The volume of financial assistance to support PTF, and more importantly in-country CSOs, is woefully inadequate to meet the needs for monitoring efforts to sustainably enhance value for money of health sector expenditures. Increases of several orders of magnitude are required. In the longer term these financial resources will have to be provided nationally but, in common with other development activities, international support will be required for the foreseeable future. Without such increases the challenge of ‘scale up’ is unlikely to be addressed. The limited donor funding that is available is often not tailored to small, local CSO needs and entails high transaction costs. Many CSOs, including PTF, do not respond to potentially attractive calls for proposals if the transaction costs are seen as too high and the chances of success low.

Moving from making a difference at local level to systemic change at institutional levels

It is clear that most PTF-supported projects successfully made a difference by reducing corruption in the daily lives of community members accessing health services. While this in itself is a considerable accomplishment, bringing about systemic change at institutional level would be even better as it can magnify and sustain outcomes. PTF-supported projects are intentionally small and local, and many partner CSOs lack the advocacy skills and national stature needed to drive policy and regulatory change. PTF believes that successful change at local levels should inform institutional change, which should be the priority of other, specialised entities. There is also too little funding to ensure greater sustainability that might contribute to higher-level change.

Gender sensitivity in project design

Many PTF projects respond to issues pertaining to women, girls, and vulnerable groups by default. Generally speaking, in health sector projects there is no lack of including women, girls, and vulnerable groups as beneficiaries. Historically, PTF has not explicitly included gender in project design and MEL, for example, through performance indicators. However, updated guidelines and processes do now include gender dimensions, such as activities to address issues emerging from gender or vulnerable group assessments carried out.

Monitoring, evaluation, and learning

Other than semi-annual progress reports and final project reports, PTF does not have a robust MEL approach for its health sector portfolio. Each CSO develops its own framework for the project it is proposing. This is time consuming, inefficient, and constrains PTF’s ability to aggregate results across the portfolio. Developing a standardised MEL framework for health sector projects with core performance indicators and standard definitions, which does not overburden our CSO partners, would help overcome this limitation.

Reflecting on the past and forging a path forward

The Covid-19 pandemic presents new obstacles to overcome regarding CSO engagement and monitoring, and may even contradict experiences during ‘normal times’. For instance, spontaneous, reactionary support for a community may be needed – thus calling for a short-term intervention, rather than a long-term solution. An emergency requires an added dose of flexibility and creativity in project design, while still upholding other success factors – especially working together with the right implementing partner.

Over more than 20 years, PTF has witnessed considerable improvement in the capacity of civil society to monitor and constructively engage at both local and national levels. Still, the way forward faces challenges that require transformational responses. The world’s current attention is focused on vaccinating billions of people – particularly in developing countries – and strengthening health systems to better handle future pandemics and other public health challenges. Vastly increased expenditures are committed but yet to be spent, and plans for even higher levels of health sector expenditures are being made in many countries.

In this context, it has become even more important and urgent that governments and donors look for innovative ways to expand their partnerships with CSOs to supplement government efforts. As reviewed in this Practice Insight, there is sufficient evidence that CSOs do play a meaningful role to supplement public health service delivery and improve results. They can do this by improving inclusion and communication channels, and delivering selected services. In addition, they can play an important and much needed role to enhance transparency and accountability in health sector expenditures through monitoring efforts.

This Practice Insight set out to assess PTF’s experiences of implementing civil society-led approaches in the health sector in order to demonstrate how CSO engagement and monitoring can be applied to prevent corruption and wastage of funds, and improve service delivery. By evaluating our experiences over the past 15 years, we have been able to draw important lessons and identify factors for success that can be used to inform ongoing CSO activities and overarching donor approaches to CSO engagement in the health sector.

First, and perhaps most critical, it is vital to choose the right implementing partner that is qualified, committed, embedded within the target community, brings with it the needed reputation, access and networks, and can be trusted.

Second, it is paramount to engage the right members of target communities by selecting a relevant issue that they are interested in, affected by, and empowered to address in a way that is coherent with the socio-political environment.

Third, constructive engagement with a number of those in positions of authority, such as elected officials, health sector staff, and others that can sustainably champion the issue(s) at hand, can provide necessary and continuous support, and offer legitimacy.

Fourth, the design and implementation of a successful project best applies a strategic, non-confrontational approach with ambitious, but realistic, time-bound objectives and tools that are fit-for-context, and that complement ongoing activities and existing priorities. This creates two particular challenges, namely, allowing for sufficient flexibility in order to react and adjust to changes in the environment, but at the same time striving for operational and financial sustainability as rigid, short-duration projects are unlikely to demonstrate long-term impact.

Annex 1: Further reading

Avis, E., Ferraz, C., and Finan, F. 2018. Do government audits reduce corruption? Estimating the impacts of exposing corrupt politicians.Journal of Political Economy126(5): 1912–1964.

Ayliffe, T., Aslam, G., and Schjodt, S. 2017. Social accountability in the delivery of social protection: Literature review. Working Paper. Development Pathways.

Bhargava, V. and Raha, S. 2015. Citizen engagement and social accountability approaches in enhancing integrity of conditional cash transfer programs. Partnership for Transparency.

Bhargava, V. et al. 2016. Civil society & development: Global trends, implications and recommendations for stakeholders in the 2030 Agenda. Partnership for Transparency.

Bhatnagar, D. et al. 2003. Citizens’ report cards on public services: Bangalore, India. World Bank.

Boesen, N. 2016. Institutions, incentives, and interests: Inspiring ideas about governance, reforms, and development partner roles in the Asia and Pacific region. The Governance Brief: Issue 28. Asian Development Bank.

Brockmyer, B. and Fox, J. 2015. Assessing the evidence: The effectiveness and impact of public governance-oriented multi-stakeholder initiatives.Transparency and Accountability Initiative (T/AI).

Clark, J. 2013a. ‘Citizens Against Corruption’ programme: Final evaluation. Partnership for Transarency.

Clark, J. 2013b. ‘Good governance: Community mobilization to combat corruption’: Final evaluation. Partnership for Transparency.

Department for International Development. 2015. Why corruption matters: Understanding causes, effects and how to address them.

Fox, J. 2015. Social accountability: What does the evidence really say? World Development 72: 346–361.

Gee, J. and Button, M. 2015. The financial cost of healthcare fraud 2015: What data from around the world shows. PKF Littlejohn LLP.

Hamal, M. et al. 2018. How does social accountability contribute to better maternal health outcomes? A qualitative study on perceived changes with government and civil society actors in Gujarat, India. BMC Health Services Research 18: 653.

Hanf, M. et al. 2011. Corruption kills: Estimating the global impact of corruption on children deaths. PLOS ONE 6(11): e26990.

Hasan, M. 2018. The skeptic’s guide to open government.Open Government Partnership.

Holland, J. et al. 2016. Empowerment and Accountability Annual Technical Report 2016: What works for social accountability. Department for International Development.

Joshi, A. 2013. Do they work? Assessing the impact of transparency and accountability initiatives in service delivery.Development Policy Review 31(S1): s29–s48.

Kaufmann, D. 2012. Rethinking the fight against corruption. The Brookings Institution.

McGee, R. 2010. Synthesis report: Review of impact and effectiveness of transparency and accountability initiatives. Social Science Research Network (SSRN).

Muir, A. and Rowley, J. 2014. Governance and transparency fund end of programme review. Coffey International Development Ltd.

Mungiu-Pippidi, A. 2017. Seven steps to evidence-based anti-corruption: A roadmap. Expertgruppen för biståndsanalys/Expert Group for Aid Studies (EBA).

Mungiu-Pippidi, A. and Kossow, N. 2017. Rethinking the way we do anti-corruption. NATO Review.

Naher, N. et al. 2020. Do social accountability approaches work? A review of the literature from selected low- and middle-income countries in the WHO South-East Asia region. Health Policy and Planning 35: i76-i96.

OECD (Organisation for Economic Co-operation and Development). 2016. Open government: The global context and the way forward.

Participatory Research of Asia. 2011. Independent assessment of PTF’s Citizens Against Corruption (CAC) program.

Partnership for Transparency. 2021c. Responding and adapting to COVID-19 response on the ground: TAP network conversations.

Partnership for Transparency. 2021d. Integrity in COVID-19 response: Civil Society Organizations (CSO) value added.Event at the Global Anti-Corruption and Integrity Forum.

Petrie, M. 2017. What is public participation in fiscal policy and why is it important?Global Initiative for Fiscal Transparency.

Read, L. and Manuelyan Atinc, T. 2017. Information for accountability: Transparency and citizen engagement for improved service delivery in education systems.The Brookings Institution.

Smith, J., Kent, B., and Case, G. 2016. Civil society: The catalyst for ensuring health in the age of sustainable development.Globalization and Health 12:40.

Stenberg, K. et al. 2017. Financing transformative health systems towards achievement of the health Sustainable Development Goals: A model for projected resource needs in 67 low-income and middle-income countries. Lancet Global Health 5: e875–87.

Transparency International. 2012. National integrity system assessments.

Verzosa, C.C. and Fiutak, T.R. 2019. The ‘how’ of multi-stakeholder engagements. The Governance Brief: Issue 35. Asian Development Bank.

WHO (World Health Organization). 2010. The World Health Report: Health systems financing: The path to universal coverage. Chapter 4: More health for the money.

WHO (World Health Organization). 2020. Potential corruption risks in health financing arrangements: Report of a rapid review of the literature.

World Bank. 2014. Strategic framework for mainstreaming citizen engagement in World Bank Group operations: Engaging with citizens for improved results.

World Bank. 2017. World Development Report: Governance and the law.

Annex 2: Overview of PTF projects assessed and objectives