Learning from People-Centered, Multi-Level Health Advocacy Campaigns

February 2021 Accountability Working Paper Number 8 Bottom-up Accountability in Uganda: Learning from People-centered, Multi-level Health Advocacy Campaigns Angela Bailey Vincent Mujune with a Preface by Prima Kazoora Bottom-up Accountability in Uganda: Learning from People-centered, Multi-level Health Advocacy Campaigns 1 About Accountability Research Center (ARC) The Accountability Research Center (ARC) is an action-research incubator based in the School of International Service at American University. ARC partners with civil society organizations and policy reformers in the global South to improve research and practice in the field of transparency, participation and accountability. For more information about ARC, please visit the website: www.accountabilityresearch.org. About ARC Publications ARC publications serve as a platform for accountability strategists and researchers to share their experiences and insights with diverse readers and potential allies across issue areas and sectors. These publications frame distinctive local and national initiatives in terms that engage with the broader debates in the transparency, participation and accountability (TPA) field. Research publications include brief Accountability Notes, longer Accountability Working Papers and Learning Exchange Reports. Rights and Permissions The material in this publication is copyrighted under the Creative Commons Attribution 4.0 Unported license (CC BY 4.0) https://creativecommons.org/licenses/by/4.0/. Under the Creative Commons Attribution license, you are free to copy, distribute, transmit, and adapt this work, including for commercial purposes, under the following conditions: Attribution—Please cite the work as follows: Bailey, Angela and Vincent Mujune. 2021. “Bottom-Up Accountability in Uganda: Learning from Multi-level, People-centered Health Advocacy Campaigns.” Accountability Research Center, Working Paper 8. Translation—If you create a translation of this work, please add the following disclaimer along with the attribution: This translation was not created by the Accountability Research Center (ARC) and should not be considered an official ARC translation. ARC shall not be liable for any content or error in this translation. Notes on Support Support for ARC comes from the William and Flora Hewlett Foundation, the John D. and Catherine T. MacArthur Foundation, Open Society Foundations, and the David and Lucile Packard Foundation. Disclaimer Support for GOAL’s ACT Health program in Uganda came from Irish Aid and UK Aid. The views expressed in this paper do not necessarily reflect the Irish or UK government’s official policies. The views and opinions expressed in this publication are those of the authors and do not necessarily reflect GOAL’s position. Keywords: Health accountability, Health advocacy, Social accountability, People-centered advocacy, Multi-level strategies, Participatory governance, Randomized control trials, Process monitoring, Citizen report cards Cover Photo: Drawing of Health Worker Vaccinating a Child. Credit: Mango Tree 2012 (commissioned by GOAL) Contents About the Authors .....................................................................................................4 Acknowledgements ..................................................................................................5 Acronyms & Notes on Use of Terms ..............................................................................6 Preface .....................................................................................................................7 Summary ..................................................................................................................9 I. Introduction ...........................................................................................................12 II. Context: Health Governance in Uganda ....................................................................18 III. ACT Health Program Principles and Implementation ................................................22 IV. Data Sources ...........................................................................................................36 V. ACT Health RCT: Study of a Community-level Intervention ........................................38 VI. Subnational Advocacy Campaigns: Citizen Actions and Outcomes .............................43 VII. Subnational Government Responses to Community-led Advocacy ............................57 VIII. Escalating Absenteeism Advocacy to National-level Officials ....................................67 IX. Discussion ..............................................................................................................71 X. Conclusions ............................................................................................................78 References ...............................................................................................................80 Annex 1. Mandates of Uganda’s executive, elected and appointed officials at various levels (focus on health) 85 Annex 2. Sample Phase 1 Action Plan (generated by community members and health workers) ...............86 Annex 3. Overview of training for community advocates ...........................................................87 Annex 4. Phase 1 Action Plan Summary – Frequency of Issues and Rates of Resolution ...........................88 Annex 5. “Commitment log” recording community advocates’ actions and government responses .............90 Annex 6. Summary of 18 campaign statements and rating of government responsiveness (as of June 2019) 91 Endnotes .................................................................................................................92 About the Authors Angela Bailey 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. [email protected] | @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 program’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 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. [email protected] | @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 organi- zation (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.” 4 Accountability Working Paper | Number 8 | February 2021 Acknowledgements First, we are in awe of the many health workers and citizens who engaged in this program and particularly the community advocates who took up the mantle of advocacy and boldly engaged government officials. This paper would not exist without the sustained dedication of staff from all of the CSOs who invested their time in the program between

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