Date: September 2017
Authors: Victoria Boydell, Jonathan Fox, Sarah Shaw
Publication type: Learning Exchange Report
Published by: Accountability Research Center, International Planned Parenthood Federation, Reproductive Health Supplies Coalition
This June 2016 Learning Exchange held at American University in Washington, D.C. convened over 40 practitioners and researchers to discuss potential contributions from the field of Transparency, Participation and Accountability (TPA) to the performance of reproductive health (RH) delivery systems.
The conversation focused on how strategic citizen oversight initiatives can facilitate monitoring of reproductive health systems and promote more accountable health systems. The main themes that emerged through the panel presentations and subsequent discussions were:
- Include multiple perspectives: Bridge political and technical analysis, the first mile, and downward accountability
- Re-politicize RH supply chains: Map power, identify incentives and collective action opportunities
- Integrate research and practice across TPA and RH: Implementation science and action research
- Anticipate challenges of applying TPA principles to RH delivery systems
The Learning Exchange culminated with discussion on possible areas of relevant collaborative research. The Learning Exchange and this document are intended to spur cross-field collaboration, practice and learning.
“While great progress has been made in placing the women at the center and delivering rights based RH services, there is still something missing if women are still perceived as ‘recipients’ or ‘beneficiaries.’ A more comprehensive definition of the ‘last mile’ as ‘first mile’ would reemphasize downward accountability—from donors, governments and providers to the women they are responsible for serving, recognizing the role of choice, agency and empowerment in contraceptive choice.”
-Learning Exchange Participant
Concept Note for Learning Exchange: Transparency/accountability strategies & reproductive health delivery systems
Systemic weaknesses, vulnerabilities or biases at different points in health systems are often the reasons why reproductive health (RH) supplies fail to reach that all- important ‘last mile’ of women wanting to use modern contraceptives. These issues, sometimes called “wicked problems” because they lack both technical certainty and political agreement, are well known but are often complex and difficult to address (Hope and Hill, 2009). Global, national, and regional stakeholders undertake valiant efforts to coordinate and build local capacity for public sector RH supply forecasting, distribution, and monitoring; however, these technical approaches may not address the full range of underlying causes that limit citizens’ choices—including inefficiency, corruption, vested interests, stock-outs, informal fees, as well as social exclusion and bias. These larger systemic issues have been acknowledged by the public health community, but have been under-addressed due to their complexity, controversial nature, and the limited capacity of technical problem-solving approaches to address deeper governance challenges. Moreover, at least in development agencies and government ministries, “sectoral” divisions tend to separate public health issues (usually framed as technical) from governance agendas (which address how the public sector is organized, including public oversight institutions and citizen engagement). In this context, disentangling the symptoms from the causes of service delivery and supply problems is easier said than done.