Abt Associates Inc. In collaboration with: Aga Khan Foundation BearingPoint Bitrán y Asociados BRAC University Broad Branch Associates Forum One Communications RTI International Tulane Universitys School of Public Health Training Resources Group Community Engagement in Health Governance: Lessons from the Philippines Derick W. Brinkerhoff Applying Health Systems Strengthening to Global Health Issues Global Health Council and HS 20/20 Brownbag Series November 4, 2010

Presentation overview Defining health governance Citizen participation in health governance QAPC demonstration project in the Philippines Lessons

What is governance?

4 Defining governance Governance is about rules that distribute roles and responsibilities among societal actors and shape interactions among them. These rules can be: formal, embodied in institutions (e.g., democratic elections, parliaments, courts, sectoral ministries) and informal, reflected in behavioral patterns (e.g., trust, reciprocity, civic-mindedness)

5 Governance and health systems

Health governance model

Health governance and power inequalities

8 Governance levels

Good health governance Responsiveness to public health needs and clients/citizens preferences. Responsible leadership to address public health priorities. The legitimate exercise of clients /citizens voice. Institutional checks and balances. Clear and enforceable accountability : Transparency in policymaking, resource allocation, and performance. Evidence-based policymaking. Efficient and effective service provision arrangements, regulatory frameworks, and management systems.

Objectives of governance participation Technical input citizen co-production of health services Technical oversight Voice Expression of preferences Feedback on satisfaction

Effectiveness of technical input & oversight depends on Existence of mechanisms to incorporate citizen input or exercise oversight Openness of providers to external input Sufficient technical knowledge and skills Link between providing input or oversight and some demonstrable desired benefit

Effectiveness of voice depends on Supportive governance structures and procedures Existence of a tradition of participation Government-interest group relations Capability of citizen groups to articulate their demands

Challenges Participation of marginalized groups HIV/AIDS The poor Women Demand-side issues Interest aggregation capacity Access & power Supply-side issues Incentives & political will Processing capacity

14 Citizens: technical input & voice facility Quality Assurance Partnership Committees (QAPCs)

The QAPC pilot in the Philippines Two LGU health facilities in Misamis Occidental: Lopez Jaena RHU and Oroquieta CHO Provincial hospital in Compostela Valley Project duration: June July 2010 Implementation through a grant to the Gerry Roxas Foundation

Facilities: CVPH, RHU-LJ, CHO-OC

What are QAPCs? Quality Assurance Partnership Committees (QAPCs) bring together local leaders, government officials, health service providers, civil society and community representatives to address issues related health service quality QAPCs can be located in health facilities or connected to local government units.

QAPC objectives Give civil society an advocacy voice in health service delivery and quality Contribute to increasing responsiveness of officials and providers to the needs of their communities for services delivered Help to solve problems related to quality of health care, services utilization, resource mobilization, and facility management

What do we mean by quality? Technical performance Compliance with technical standards Access to services Lowering barriers (geographic, social, economic, linguistic, cultural) Effectiveness of care Achievement of intended health results Efficiency of care Cost containment in achieving intended results Interpersonal relations Communication, trust, respect, confidentiality, responsiveness Continuity of services Provider consistency, timely/appropriate referrals & lab results Safety Minimized risk of injury, infection, & side effects Physical infrastructure Amenities: appearance, cleanliness, comfort, privacy Choice Client autonomy in choosing provider, treatment, insurance plan; access to information to exercise choice

Which dimensions of quality can QAPCs help to improve? Not all dimensions are appropriate for QAPCs QAPCs can most readily help with Access to services Utilization of services (through community mobilization) Interpersonal relations Physical infrastructure Choice

Making QAPCs operational Assuring that selected civil society members represent community views and concerns Building understanding of the roles and responsibilities of QAPCs Providing QAPCs with the resources necessary to function Ensuring that QAPCs operate as partnership mutually agreed goals and activities encouragement of contributions from all members

Composition of QAPCs QAPC Profile Composition CommunityService Provider Total CommunityService ProviderFemaleMaleFemaleMale Lopez Jaena Associations Individuals SB MHO RHM PHN SI Oroquieta City NGOs Associations Vice Mayor SP CHO Assistant CHO DoH Rep Budget Officer HEPO RHM PHN

Composition of QAPCs QAPC Profile Composition CommunityService Provider Total CommunityService ProviderFemaleMaleFemaleMale Compostela Valley Individuals Chief of Hospital Admin Officer Nurse MHO Physician

Examples of QAPC activities IEC campaigns (LH, CVPH, OC) Client satisfaction survey (CVPH) Improvements in patient referral system (OC) Advocacy with local government officials re health budgets, medicines availability, staffing (LH, CVPH, OC)

IEC meeting, Lopez Jaena QAPC

Service delivery outcomes Client-focused and responsive MCH service delivery Expanded outreach from the facility to MCH service users Increased MCH service utilization Increases in facility-based births Increased uptake of family planning

Client responsiveness: CVPH

Governance outcomes Increased responsiveness to community needs and preferences At health facilities Among local government officials Some increase in accountability Ex: facility managers have taken community- raised issues into account in resolving complaints re providers.

ComVal QAPC and Governor Uy

Sustaining the QAPCs Integration of the QAPC in the CVPH Wellness Program Provision of honoraria to community representatives included in the 2011 budget of the Province of ComVal Creation of the Mobilizing Transformers in Barangays (MTB) at the barangay level in Oroquieta City Approval of budget for transportation allowance of community representatives to attend QAPC activities in Lopez Jaena Coordination between QHIT and QAPC in management feedback in the three facilities

Lessons Community commitment and capacity Supportive facility staff open to participation Membership criteria Local leadership Structural incentives (decentralization) Links to existing service quality programs Resources

Abt Associates Inc. In collaboration with: Aga Khan Foundation BearingPoint Bitrán y Asociados BRAC University Broad Branch Associates Forum One Communications RTI International Tulane Universitys School of Public Health Training Resources Group Thank you Reports related to this presentation are available at