Abstract

This paper distils the key insights from thematic and inter-thematic deliberations of the Global Symposium on Citizenship, Governance and Accountability in Health. It describes the evolution of the symposium theme on linking accountability to citizenship and governance in health while providing an overview of the symposium. The paper further synthesises the key discussions of the core-themes, lays out analytical reflections that have emerged from the deliberations that touch upon the issues of power and politics surrounding accountability, viz civil society, democracy, power, civic space and the role of private non-state actors that affect health rights of the marginalised.

COPASAH – A southern network of accountability practitioners

The Community of Practitioners for Accountability and Social Action in Health (COPASAH)¹ evolved as a global network of practitioners through the processes of positioning social accountability at the core of the claim for the human right to health. COPASAH was initiated in 2011 by a group of health rights practitioners from the global South advocating for accountability. In contrast to the dominant technocratic, tool-based method, and power-neutral accountability perspectives, the network centre-stages the transformative potential of community-led and community-centred accountability to strengthen the rights to health and citizenship of the marginalised. COPASAH has provided global leadership in forging solidarity between community leaders, organic intellectuals, academia, and institutions to advocate for the transformative potential of community-centred accountability. The Symposium was organised from October 14 to 19, 2019, as part of this process of building global solidarity of campaigners for accountability, to exchange experiences and build critical discourses on social accountability.

In this paper we distil key insights from the COPASAH deliberations on Citizenship, Governance and Accountability in Health. After a brief context setting, this paper presents an overview of the symposium and the key discussions woven around the core themes. It is followed by analytical reflections on the critical discourse emerging from the deliberations.

The policy context and thematic grounding

The symposium placed accountability within the broader context of citizenship and governance for health. The Sustainable Development Goals (SDGs) sharpened this focus under the symposium’s sub-theme—Leaving no one behind: Strengthening community centred health systems for achieving sustainable development goals (1). The theme of the symposium evolved through four policy-centred perspectives concerning health systems in the contemporary era:

(i) the standard of the human right to health and “Health for All” (2, 3) as the benchmark for all citizens to reimagine universality and equity in health;

(ii) the fragmented public healthcare systems in developing countries increasingly being rendered fragile by the burgeoning and unregulated commercial and corporate healthcare interests blurring the boundaries between public and private healthcare, with implications for practices and discourses on accountability (4);

(iii) the State repositioning itself as a facilitator of private-corporate interests, evading accountability to citizens and, making the accountability chains quite complex for people to negotiate (5); and

(iv) undermining the transformative potential of the accountability processes, through limited, instrumentalist and reductionist accountability discourses that are devoid of power and equity perspectives.

Realising that a process of social accountability is only possible through strong bonds between community and global solidarity, the symposium firmly located accountability in the larger canvas of strengthening citizenship and governance, and in furthering the community’s role in building people oriented, equitable and accountable health systems (6).

A brief overview of the Symposium

Along with COPASAH, the symposium was jointly hosted by five international organisations.* The five hundred delegates represented forty-eight nationalities and diverse cultural geographies that included indigenous people from Latin America, members of the Roma Community from Macedonia, practitioners from fifteen African nations, Dalits and Adivasis — indigenous and marginalised groups from India ─ transgender persons and people with disabilities. While English speakers formed the largest contingent, Spanish, Portuguese, French and Hindi speaking delegates formed a large proportion of the delegates. At the conclusion of the symposium, a Social Accountability Charter with highlights from the four-day proceedings was released. Two hundred delegates contributed to it through presentations, posters, case stories, discussions and sharing of experiences (7).

Thematic and intersectional deliberations on accountability practices

Five key themes were finalised through consultations before the symposium. These were:

• Community participation in accountability for health systems strengthening ‒ focusing on the potential and power of communities to demand accountability;

• Rights of indigenous people and accountability focused on their access to public services against the backdrop of their shared histories of marginalisation;

• Sexual-reproductive health and rights (SRHR) theme centre-staged community-led social accountability practices that negotiate the politics of sexual and reproductive health rights;

• Setting the framework and agenda for people-centred accountability of private and corporate healthcare sectors, an emerging theme in the global health discourses, discussed from the experiences of practitioners from South Asia and Africa on the lack of state regulation leading to the non-accountability of the profit driven private healthcare sector;

• Forging alliances between healthcare workers and communities focused on marginalisation and conflicts between the healthcare workers and community (8) within the context of strong power hierarchies within the society and healthcare systems that influence the interrelationship between community and women health workers, appreciating the challenges as well as opportunities for fostering accountability.

The plenary sessions highlighted the ambiguity that is prevalent in linguistics and terminology, and the technocratic control and top-down approaches that characterise the dominant global practice of accountability. Generally understood as the processes of holding the political and administrative authorities to account, accountability has been used more as a tool for tactical outcomes and some practitioners use it as a strategic tool with a long-term impact perspective (9). The discussions in the plenaries as well as inter-thematic sessions acknowledged these ambiguities, the lack of a cohesive definition of accountability, and the reality of it being reduced to mere score cards and audits.

One of the key propositions of the symposium was that concerning communicating accountability strategies and developing conceptual and cross-cultural translation of the term “accountability”. In the inaugural plenary, Aruna Roy of Mazdoor Kisan Shakti Sanghathan, a premier people’s collective in the field of transparency and accountability, raised the slogan, “Our rights, your accountability” and said, “today we are all here to speak truth to power, as accountability is nothing else but speaking truth to power”. She emphasised that social accountability is the next step towards taking forward the citizen’s right to information (10).

The symposium was taking place in India even as the citizenship crisis was unfolding on a great scale in several parts of the world, including among others, the Rohingya refugee crisis in Myanmar, conflict and displacement in Syria; and in India, the issue of the National Register of Citizenship (NRC) in the state of Assam which aimed to exclude 1.9 million Muslims from citizenship (11). The issue of citizenship and treating the marginalised as non-citizens without any rights resonated through the symposium sessions. The accountability of states, international human rights bodies and other ombudsman bodies and national policies was questioned by the community leaders and discussions were also juxtaposed with the issues of the shrinking welfare state, fragmentation of governance systems and elusive accountability as experienced by disadvantaged communities globally.

The delegation of Roma people from Macedonia, Bulgaria and Romania, and Dalit and indigenous communities in South Asia, placed before the symposium their examples of living as non-citizens and how it has furthered their marginalisation. Through the course of the symposium, the exclusion and discrimination against minorities, Muslims, diverse ethnic communities in Africa, as refugees and internally, was spoken about in depth. Great concern was raised over the political machinations that right wing and neo-liberal governments devise to create citizenship disruptions by declaring some people as non-citizens. Citizenship forms one of the firm foundations for the moral claims of accountability from the State. That citizenship itself is being questioned is a matter of grave concern as expressed by many participants.

The speakers located the accountability discussions in the context of the State becoming fragile, increasingly being influenced by non-state and corporate actors, and marked by abdication of its responsibilities towards citizens. A human rights lawyer from Uganda said that the State in the global South has been painted as “entities that cannot deliver” hence making a rationale for non-state actors to subvert governance in the guise of delivering services. Several examples were provided to explain the global agenda setting done by non-state and private-corporate actors as seen in funding of WHO which minimises the power of nation-states. In several countries basic services such as water, electricity, and transportation facilities have either been privatised or channelised through “private public partnerships”. By these means, public money is being diverted to private actors shrinking the role of the State which is no more “accountable’” to citizens. The overall impact is a compromise in state accountability.

There was general agreement among participants that the state is regularising private players not regulating them. They deliberated on the need for practitioners of accountability to understand how the state works, the need to look at human rights on global solidarity and obligations beyond borders as the need of the hour. The suggestion was put forward to have global accountability dialogues and to formulate global processes to hold non-state actors accountable.

The symposium’s central focus was the paradox of citizen participation which is central to accountability and the shrinking civic and democratic spaces. The political context of rising authoritarianism even within elected democracies, right-wing politics, and religious polarisation which affect the foundations of citizenship were noted as comprising the key contemporary political context within which accountability must be located.

Authoritarianism which leverages centralisation of political and economic power, creates narratives of polarisation based on “nationalism” and is seen to conflate religion with citizenship. Globally, neo-liberalism with crony capitalism has intensified inequity and poverty. In such a scenario, how to sustain participation in times of the citizenship crisis and to expand the civic space, were the key questions placed upfront. Increasingly, as civil society itself is getting polarised within such a political agenda, an accountability discourse needs to include conversations about politics, democratic and liberal values, and about how we define ourselves as civil society.

Delegates from CIVICUS, a civil society organisation from South Africa presented their study and reports which noted the rise of authoritarian regimes as the key factor which has shrunk the civic space (12, 13). The report notes that 111 countries in the world have serious civic space restrictions. These are manifested in backlash to organisations providing fundamental life-saving services, censorship of the press, preventing people from accessing news, internet shutdown etcetera. The organised civil society groups that are harassed and targeted include women’s groups, labour unions, and groups working on environmental and indigenous people’s issues. Attacks on human rights defenders were reported from participants from Guatemala and Columbia.

A researcher from Accountability Research Centre (USA) based on her work in Brazil, Cambodia, Ethiopia, Nepal, Pakistan, and Zimbabwe, expressed the view that the civic space is changing, rather than closing. Such a change can be seen in the new actors especially right-wing actors occupying the public space with their unruly politics, usage of digital public space changing public discourses. Leaning towards authoritarianism, intolerance of diverse opinions coupled with populist politics and polarisation were noted as common features across the world whether the country is poor or rich. Informal means like threats and intimidation being used to close the space is common across these countries, dividing civil society in the name of “protecting our values” against “foreign values” , shutting down NGOs, and suppression of all dissent. The presentations noted the overall pattern in the move towards authoritarianism that includes exclusionary policies crafted without people’s participation and shutting down civic protest to deliver rapid economic social transformation. Elimination of the civil society space for questioning and dissent is seen as the primary strategy to circumvent any accountability.

The discussion that ensued was based on a common understanding that SDGs and the principle of “leaving no one behind” is unlikely to be achieved with the closing of civic spaces. On a positive and hopeful note, it was stressed that the accountability discourse must be broad-based beyond the health sector, must move out of a situation of fear and intimidation; coalitions must be formed and strengthened; and a global movement for social accountability must be built. The presentations and studies noted the rise of people’s power in an unprecedented manner, with civil society getting organised in nontraditional spaces and outside the previous formal spaces. The symposium endorsed the need for building broad-based alliances, engaging with donors and global spaces to build global solidarity of citizens, and to evolve innovative methods of strengthening civic voices and mobilising resources for accountability.

Two sets of experiences of working closely with the government in India were presented for discussion and brought out the differential behaviour of the State in varied policy contexts. These brought out the very contradictions that are inherent in Indian society where caste-based discrimination is a social norm. The representative of an organisation located within the state accountability system, closely anchoring the processes of transparency and accountability in the state of Telangana in South India, outlined that social audits conducted twice a year in every gram panchayat (local democracy institution at the village level) helped to bridge the disconnect between citizens and government officers. Based on her decade-long experience of working with the government and institutionalising accountability protocols, she explained that transparency and accountability are complementary. In India, social accountability has been able to address matters which the transparency law (Right to Information Act) has not been able to answer. Now, a stage has come where social accountability must be converted into a law to strengthen the citizen’s right to hold governments accountable. Such processes however yield positive dividends only under the gaze of a watchful civil society.

Safai Karmachari Andolan (SKA) is the campaign in India for the eradication of manual scavenging and to uphold the rights of municipal sanitation workers (Safai Karmacharis). Most people engaged as street sweepers, toilet/sewer tank and manhole cleaners, and night soil carriers in India belong to the most marginalised Dalit communities, most of whom are not even accorded the status of permanent workers, and barely treated as equal citizens in reality. When safai karmacharis in the movement pose questions, they are ignored or reviled and when the questioning assumes collective strength, they are labelled as “anti-government”. A national leader of the SKA stated in a plenary that, in 2019 alone, 1878 manual scavengers had died while cleaning sewer tanks, and it had neither hit the headlines, nor evoked any national outcry (14). Governments acknowledges no accountability for the lives and rights of sanitation workers cleaning faeces from the same toilets that it is constructing en masse under the Swacchh Bharat Abhiyan (Clean India Campaign), despite the enactment of a law (15) promulgated after a long struggle to eradicate manual scavenging. On the other hand, in several places, the aggressive Clean India Campaign has resulted in upper caste people lynching Dalit persons for defecating in the open as they do not have a place of their own to build toilets (14).

The symposium endorsed the fact that even as the processes of demanding accountability continue, civil society needs to leverage spaces of engagement with the State to safeguard human rights and to hold the State accountable.

The issue ‘How do we reclaim accountability and what is the role of the local and global actors?’ was deliberated on at a plenary. Delegates from the International Budget Partnership (IBP) engaged at the global level in analysing budgets to demand fiscal and budget accountability, provided the framework of analysis for such a task. This approach aims primarily to diagnose whether the accountability gap is due to a technical error or a wrong policy based on lack of evidence or is a system-based outcome. Presenters from Latin America, closely engaged with the indigenous populations, elaborated that leaving communities behind is not an accident or a technical error, but the result of a deliberately framed system that excludes the indigenous populations. The experts in budget accountability reiterated that addressing this requires systematic analysis and an approach that aims at systemic change.

This marginalisation, which is manifest in human rights violations, cannot be addressed just by improving data quality or indicators. The strategy is to force those in power to stop abusing power. Understanding accountability bottlenecks implies understanding power and power relationships, and we need to think about how people can be instrumental as citizens’ agency or as a core part of the strategy. It was pointed out that examining this through the systemic lens facilitates the deployment of strategies and resources that are critical to buttress citizens’ action. Practitioners, however, are always confronted with the dilemma of choosing between a confrontational or a co-operative approach. Practitioners do have to engage with service providers to obtain critical information, as quite often they too are sympathetic, being victims of certain policies of the system. The Latin American participants felt such individuals could at best be used as whistleblowers. A delegate spearheading the African Health Budget Network in West Africa, speaking from his experience at both local and global levels, stressed the need for strengthening solidarity at multiple levels of engagement to respond to the backlash against human rights defenders. A Ugandan speaker, underscored the need to work vertically and horizontally with all sectors beyond the health sector such as trade, investment, genetically modified organisms (GMO), the food system, debt and aid, as well as climate change to strengthen accountability in health.

Through the deliberations, there was considerable agreement that strategising for accountability requires robust systems analysis, alliance building at multiple levels and sharpening of strategic approaches that includes navigating power, working politically and redesigning systems.

The symposium raised several questions on the positioning of SDGs and Universal Health Coverage (UHC) in the context of increasing inequities, conflicts, and stifling of civil society voices. Participants raised concerns about: how UHC has slowly morphed into universal insurance coverage, focused only on facilities and not people; and about the acute lack of resource allocation for health systems strengthening. It was noted that the inequities that marginalised communities face are masked by national averages used to show improvement in SDGs (16). Panelists in SRHR sessions raised the concern that some critical issues such as abortion do not figure in UHC and there is no clarity about where several issues related to reproductive rights fit squarely into the UHC agenda. The delegates also noted that civil society across the globe has been co-opted into the uncritical SDG and UHC discourses, a majority felt that, from an accountability lens, a strong critique of this approach needs to be put forward. There was also general agreement on the fact that an uncritical acceptance of UHC, especially in a non-responsive health system, is designed to pave the path for entry of the private healthcare sector. Latin American health advocates pointed out that accountability challenges the complex web of systemic corruption, leading to retaliation against accountability advocates. A speaker from Uganda highlighted the unaddressed issues surrounding UHC that included the rising dominance of the private sector in health and other sectors, involvement of transnational corporations, and continuing withdrawal of governments from the provision of health services. Even within the health sector, the growing shift in resources from preventive to curative services, investment in infrastructure and technology rather than in human resources, and shelving of citizens’ participation are issues that need to be questioned and addressed if SDGs are to be a reality for marginalised populations.

The field of accountability closely interfaces with evidence generation, research, monitoring and evaluations, and social audits which adopt rigorous methodologies. Critical questions on contextualising research for accountability were debated across the symposium sessions. Researchers from premier research institutions spearheaded the introspection of the research community even as they gave a call for more relevant research which could unlock troubling issues arising in the quest for citizenship and accountability.

Critical questions on research funding and the undue influence of donor-driven research came up very prominently in the presentations. Researchers from Colombia University contended that research agendas are dominated by donor priorities instead of community priorities, and they are under pressure to create a narrative of success. There are also policy restrictions on researching some issues concerning communities, and the US Global Gag Rule (17) was cited to illustrate the blockade on research related to abortion. It was emphasised that accountability focused research needs to be innovative.

The power dynamics that marks research and the resistance of academic researchers to engage with studies aimed at “shifting power” were other issues that recurred throughout the deliberations. A researcher and accountability advocate from Guatemala emphasised the need to make research relevant to communities; and even while doing so, practitioners invited the research community to introspect on “Who asks the question, who decides what question is right, and what process and methods are appropriate to ensure participation of people?” It was noted that knowledge reaching the right people is the key to shifting power. It was contended that the current practice of knowledge dissemination is top-down, therefore there is a need to re-focus on the bottom-up knowledge making process, to document, analyse and re-conceptualise what it means for accountability. Stressing the need for community-centred accountability research, the symposium underscored the demand for communities’ participation in framing the right research questions and a relevant design.

The delegates who had engaged with research lamented the pitfalls of donor and academic emphasis on randomised controlled trials (RCT) which are robustly funded and tend to crowd out other research methods. While inviting researchers to capture the relevance of multi-level approaches to societal change, they also underlined the imperative for research to raise structural and power issues that perpetuate marginalisation, to unlock the transformative potential of accountability processes through research. It was pointed out that along with shrinking space for civil society, the space for people-oriented research focusing on inequalities hardly attracts funding as it invariably intersects the domains of politics, governance, and democratic rights. The research related discussions articulated a research agenda for accountability that included prioritising grassroots experiences to unpack the state as an organisation and its working, the issue of private sector-and state relationship, accountability of non-state actors and their role in setting global agendas in accountability discourses.

The deliberations of the symposium were encapsulated in the COPASAH Social Accountability Charter finalised through a participatory process with the involvement of the wider accountability community. The draft was discussed in the five assemblies in the symposium, and the final version. was adopted and endorsed by the general assembly, as the ‘COPASAH Charter and Call to Action for Social Accountability for Health’ (18). The charter sets forth the broad vision on how citizenship, governance and accountability processes must contribute to the better health and wellbeing of all, most importantly, of marginalised and deprived communities. In additions to deliberations on citizenship and accountability, all the participants subscribed to the spirit and content of the Charter as a measure to take the struggle forward. The Charter on Social Accountability and Call to Action (18) will act as a guide for all practitioners in the post-symposium period.

The period following the symposium has been marked by the global crisis of the Covid-19 pandemic, presenting unprecedented and new challenges that stimulated the raising of civil society voices for state accountability. The spirit of the social accountability Charter continues to inspire practitioners to demand political accountability from the State towards its citizens and of the global community towards the stateless and non-citizens.

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*The Global Symposium on Citizenship, Governance and Accountability in Health was organised by COPASAH, and co-organised by People’s Health Movement (PHM), Azim Premji University (APU), Accountability Research Centre (ARC) –American University (Washington DC), Institute for Development Studies (IDS), Sussex and Program on Global Health Justice and Governance (PGHJG) of Mailman School of Public Health, Columbia University, New York, from October 14-19, 2019.

The Symposium Organising Committee, consisting of the Steering Committee of COPASAH and the co-organisers, deliberated on the character of the symposium along with over a hundred national and international partners who were a part of the symposium preparatory processes. Accordingly, a diversity of practices, participatory methodologies, , multiple interactive media and personal interactions were to be the key to curating the symposium.

Detailed reports of the deliberations are available from: https://www.copasahglobalsymposium2019.net/

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