Bottom-up Accountability in Uganda: Learning from People-centered, Multi-level Health Advocacy Campaigns
Date: February 2021
Author(s): Angela Bailey and Vincent Mujune, with a preface by Prima Kazoora
Publication type: Working Paper
Published by: Accountability Research Center
Uganda’s laws, policies and health sector strategies codify openings for citizen participation in planning and monitoring government services, yet these spaces are often inaccessible in practice. In response to this, a consortium of civil society organizations led by GOAL designed and implemented the Accountability Can Transform Health (ACT Health) program in Uganda from 2012 to 2018. This paper draws on program monitoring data, empirical evidence, and supplementary interviews to analyze how and the extent to which the ACT Health multi-level, people-centered advocacy campaigns strengthened accountability for health from the bottom up.
The ACT Health program reviewed in this paper had two distinct phases. Phase 1, from 2014 to 2016, included a series of CSO-facilitated dialogues between community members and health workers in 282 government health facilities. These yielded action plans, which were then reviewed in follow-up meetings every six months. Phase 1 was designed to be evaluated through randomized control trial (RCT) research, which tested the impact of citizen report cards (information) and community-level dialogues on a series of 12 outcome indexes.
Phase 2 of the program added a new approach: accompanying networks of volunteer grassroots community advocates from 98 health center catchments in 18 districts to organize, design, and deliver multi-level advocacy campaigns. In Phase 2, from 2016 to 2018, 396 community advocates identified advocacy priorities, then planned and delivered advocacy campaigns to a wide range of government officials up to the national level. In 14 districts, communities built advocacy campaigns around the complex issue of health worker absenteeism.
This working paper is a practitioner-led analysis of the full ACT Health program. The paper contextualizes key RCT findings, then explores outcomes and learning from the cycles of citizen-led engagements and government responses during Phase 2 advocacy campaigns.
Angela Bailey Angela began working at the Accountability Research Center (ARC), an action-research incubator based at American University in Washington, DC, in August of 2016. Prior to joining ARC, Angela worked for international NGOs in various capacities in Liberia and Uganda. From April 2014 to June 2016, Angela worked with GOAL as program director of the Accountability Can Transform Health (ACT Health) program in Uganda. Angela holds a Master’s in International Affairs from Columbia University’s School of International and Public Affairs. abailey@american.edu | @participangela. I began working in Uganda in 2009 and during an eight-month consultancy in 2012, I helped GOAL to develop the ACT Health program approach. I compiled a literature review, conducted key informant interviews, and co-created the initial theory of change. When GOAL secured a larger grant to expand the ACT Health program, I was hired as the ACT Health program director and oversaw all aspects of planning, implementation, monitoring, and learning. I also worked closely with my co-author Vincent Mujune during the initial year of planning, preparing, and piloting of the people-centered advocacy approach before leaving Uganda in June 2016. In February 2018, I re-engaged with Ugandan colleagues and community advocates to better understand the processes and outcomes of the people-centered advocacy campaigns accompanied by the ACT Health program. While I have an intellectual stake in this analysis given my role in the pro-gram’s design and implementation, the time and physical distance enable me to critically examine and reflect on the effects of the people-centered advocacy work.
Vincent Mujune Vincent led GOAL’s people-centered health advocacy work in Uganda from May 2016 to December 2020. He supported community-led processes using participatory evidence-generation and analysis methods to engage affected communities, build their capacities and strengthen the influence of marginalized households on the health system. Vincent is a member of Uganda’s Civil Society Budget Advocacy Group and has trained civil society actors on people-centered advocacy in Sri Lanka, Malawi, and Sierra Leone. vincentmujune@gmail.com | @vincentmujune. I started working with GOAL in 2014, initially supporting organizational development among GOAL’s many civil society partners. In 2015, based on my experience supporting direct advocacy by persons with lived experience of mental ill health, I began to develop materials and pilot the people-centered advocacy work in Bugiri District in 2015. In May 2016, I became Deputy Director of the ACT Health program. I was instrumental in supporting and guiding civil society organization (CSO) teams as they prepared community advocates to drive their own campaigns. This included refining training tools and processes, delivering workshops, and providing ongoing supervision and feedback to CSO staff in all districts.
Positionality: Practitioners as Authors As co-authors of this paper, we acknowledge our roles as architects and stewards of the ACT Health program. Our closeness to the implementation brings strengths and weaknesses. As self-critical practitioners committed to learning and advancing participatory governance, our closeness to the ACT Health program enables us to bring to light multiple dimensions of a multi-level strategy and offer insights into the “black box of implementation.”
