Accountability to Citizens on Gender and Health

This background paper was commissioned by the Women and Gender Equity Knowledge Network (WGEKN) of the World Health Organization (WHO) Commission on Social Determinants of Health, 2006/2007. The network was led by Dr. Gita Sen and Dr. Piroska Osltin. It was written to review the practice of accountability to citizens on gender and health, including lessons, gaps, and recommendations. It opens with a political briefing containing 5 key problems and 5 key recommendations related to accountability to citizens on gender and health:
Key Problems:

1. Previously, as stated in the document, the health sector has not been adequately held to account to reduce gender inequalities in health or comprehensively address gender-specific health needs of women and men.
2. There are few mechanisms for citizens to hold private health sector, public-private health partnerships (PPPs), multilateral financial institutions, and health donors to account.
3. Power holders in the health sector have not been accountable to marginalised women or men.
4. International treaties relevant to gender and health accountability have not been ratified by all countries. Only a few countries have passed accountability legislations, like rights of citizens to participate, access information, and litigate on others' behalf. Right to health and gender equality is, again, guaranteed only in a few countries.
5. The pre-conditions - vibrant democracy, political will, and resources - for making accountability mechanisms work for reducing gender inequalities in health are not present in several countries.

Key recommendations:

1. "Strengthen accountability to gender and health through the following measures:
   
   • Visibilising gender and health issues in the eyes of all stakeholders;
   • Engendering health accountability structures, tools and processes;
   • Weaving in health into gender accountability mechanisms;
   • Supporting use of Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) by civil society organisations (CSOs) to hold governments accountable to gender and health; and
   • Establishing a gender and health accountability desk within WHO and Ministries of Health of national governments.
2. Strengthen accountability of new health actors through the following measures:
   
   • UN monitoring of adherence of PPPs, multilateral financial institutions, and health donors to international agreements;
   • Strengthening representation and participation of rights based citizens’ groups in the boards of the above actors; and
   • Extending public sector accountability legislation to the above actors.
3. Strengthen accountability of power holders to marginalised groups through enhancing the latter’s access to information, accountability spaces, and negotiation skills, and improving capacity of power holders to be accountable.
4. Pressurise all countries that have not signed and ratified relevant health and gender related international treaties to do so, as well as pass accountability legislations and right to health/gender equality legislation.
5. Strengthen democracy, political will and resources through implementing Recommendation 4, supporting growth of CSOs, and pressing donors/government to allocate resources to engender accountability mechanisms and outcomes."

Further, the following five strategic tools are presented which have been used by citizens to promote accountability of health policy makers, managers, and providers to gender and health: use of international human rights instruments, agreements reached in gender/health-specific conventions, Millennium Development Goals (MDGs), and other targets; use of new aid infrastructures - Poverty Reduction Strategy Papers (PRSPs) and Sector-Wide Approach (SWAps); use of progressive legislation on rights of citizens to accountability; use of, as well as advocating for, gender-sensitive health legislation, policies, programmes, and budgets for furthering accountability; and use of community-level health structures, funds, and audit tools.

The document presents case studies in which CSOs and allies apply pressure to health departments and providers for provision of gender-specific services, enforcement of non-discrimination policies, and accountability. In one case, to advocate for breast cancer screening in Ghana, copies of a video of a United States television programme with a popular American actress on her experience with breast cancer were shown in beauty parlours and hair salons. Regional rallies, including dissemination of information on self-exams, and campaign fundraising followed the video distribution. The practice of sex-selective abortion in Tamil Nadu, India, was the subject of a campaign which used clinic visits, clinic registration for awareness of and commitment to national laws against the practice, and data monitoring to press for policy enforcement. In India, Bangladesh, Pakistan, and Nepal, 6 women's non-governmental organisations (NGOs) partnered with the Asia-Pacific Resources Research Center on Women to advocate directly, and through CBOs, for safe motherhood and young people’s sexual and reproduction health (SRH) services. The partnership observed that good policies exist on safe motherhood, but implementation was weak. They worked at the community level on raising awareness of legislation, policies, and programmes so that the CBOs would put pressure from the bottom on health services to, among other things, scale up staffing, and maintain their mandated schedules. In Peru, women's organisations used the government's ratification of CEDAW to hold a provider in a public hospital to account for raping a woman patient.

Among the closing communication-related recommendations the document suggests are the following:

• applying the accountability strategies used in the public sector to the private sector;
• translating health policy, budget documents, and programme materials into local languages and making them available through print, audio, and visual mass media;
• forming associations among marginalised populations and promoting tools for advocacy among them;
• sensitising media, religious leaders, health providers and managers, and elected government representatives on gender equity health issues;
• encouraging CBOs to prepare shadow reports on status of civil and political rights and to put forth candidates for election, as well as pressure governments to sign on to international accountability protocols;
• and requesting that the WHO establish an "Accountability Desk...vested with the responsibility for institutionalising concerns of accountability to citizens within all programmes of other departments with governments, public-private partnerships, social research institutions, and civil society organisations, as well as coordinating a global programme on strengthening accountability to citizens on health in general, and gender and health in particular. Similar structures may be evolved at the regional and country offices of the World Health Organisation (WHO), as well within Ministries of Health of national governments."

An updated, condensed and analytical version is available in: Murthy, R.K, 2010, Accountability to Citizens on Gender and Health in Gender Equity in Health: The Shifting Frontiers of Evidence and Action, edited by Sen, Gita and Ostlin, P, 2010, New York/London, Routledge

Click here to download this document in PDF format.

WHO website, June 2007; and email from Ranjani K. Murthy to The Communication Initiative on August 19 2010.