Promoting Partnership and Participation in the Context of Decentralization to Improve Sexual and Reproductive Health in

Karen Hardee

Much of the work undertaken by the USAID-supported POLICY Project in Latin America and the Caribbean (LAC) has been based on the premise that improving partnership between governments and civil society and strengthening participatory processes in the region can help improve the decentralization of the health sector. Working in Bolivia, Peru, Mexico, and Guatemala, the project has helped governments and civil society clarify their roles and strengthen decision making at the central, state, and municipal levels. The project has used its limited funds to intervene strategically to motivate citizens and build capacity of civil society organizations to participate as partners with governments in policymaking and governance and to convince government officials that sharing power and collaborating with civil society serves the interests of the country and its government.

Health Reform, Decentralization, and Participation in Latin America: Protecting Sexual and Reproductive Health POLICY Project Project August 2000 Chapter 1 Promoting Partnership and Participation in the Context of Decentralization to Improve Sexual and Reproductive Health in Latin America and the Caribbean Authors: Karen Hardee, Mario Bronfman, Taly Valenzuela, and William McGreevey Chapter 2 Bolivia Case Study Authors: Guido Pinto, Sandra Alliaga, Varuni Dayaratna, Charles Pedregal, and Beatriz Murillo Chapter 3 Mexico Case Study Authors: Martha Alfaro, Edgar Gonzalez, Francisco Hernández, and Mary Kincaid Chapter 4 Peru Case Study Authors: Ellen Wilson, Patricia Mostajo, and Edita Herrera Chapter 5 Guatemala Case Study Authors: Lucia Merino, Cindi Cisek, Mirna Montenegro, and Lilian Casteñeda Chapter 6 Promoting Successful Participatory Decentralization: Lessons Learned from Policy Activities Authors: Mary Kincaid, Taly Valenzuela, and Sandra Alliaga LATIN AMERICA & THE CARIBBEAN Contents Foreword ................................................................................................................ v Acknowledgments ...................................................................................................... vi Contributors ............................................................................................................... vii Chapter 1: Promoting Partnership and Participation in the Context of Decentralization to Improve Sexual and Reproductive Health in Latin America and the Caribbean ......... 1 Introduction .......................................................................................................... 2 Government and Civil Society Partnership to Implement the ICPD Programme of Action ......................................................................................................... 2 Decentralization .................................................................................................... 3 Participation of Civil Society at the Decentralized Level .......................................... 6 Types of Decentralization that Promote Participation ............................................. 7 Continued Challenges to Promoting Partnership and Participation ........................ 9 Chapter 2: Bolivia Case Study .................................................................................... 11 Introduction ........................................................................................................ 12 Context .............................................................................................................. 12 Geographic, Social, and Economic ............................................................... 12 Decentralization and Participation: A Favorable Legal Climate ...................... 13 Sexual and Reproductive Health Policy: A Changing Landscape, 1970–2000 13 Challenges .......................................................................................................... 14 Interventions and Results .................................................................................... 14 Making Municipal Planning Processes Participatory ....................................... 15 Building a Cadre of Leaders and Advocates for Sexual and Reproductive Health .................................................................................................... 17 Supporting Advocacy for Gender and Sexual and Reproductive Health Issues: From Skills-Building to Action ........................................................ 17 Collecting and Using Information at the Local Level ..................................... 18 Conclusion .......................................................................................................... 18 Chapter 3: Mexico Case Study ................................................................................... 21 Introduction ........................................................................................................ 22 Context .............................................................................................................. 22 Geographic, Social, and Economic ............................................................... 22 Decentralization and Participation ................................................................ 23 HIV/AIDS Policy: Preventing the Spread of the Pandemic .............................. 23 Challenges .......................................................................................................... 24 Interventions and Results .................................................................................... 24 Developing a Participatory Planning Approach to HIV/AIDS at the State Level ........................................................................................................ 25 Journalists as Allies and Participants .............................................................. 26 Bringing Key Actors Together to Forge Alliances and Develop a Multisectoral Plan ......................................................................................................... 26 Helping to Sustain the State Planning Groups ............................................... 27 Outcomes ........................................................................................................... 28 Conclusion .......................................................................................................... 30 Chapter 4: Peru Case Study ....................................................................................... 31 Introduction ........................................................................................................ 32 Context .............................................................................................................. 32 Geographic, Social, and Economic ............................................................... 32 Decentralization and Participation ................................................................ 33 Sexual and Reproductive Health Policy ......................................................... 33 iii Challenges .......................................................................................................... 34 Interventions and Results .................................................................................... 35 Building Skills at the Decentralized Level ....................................................... 35 Putting Lessons into Practice ......................................................................... 35 Achieving Results .......................................................................................... 36 Conclusion .......................................................................................................... 39 Chapter 5: Guatemala Case Study ............................................................................. 41 Introduction ........................................................................................................ 42 Context .............................................................................................................. 42 Participation ................................................................................................. 42 Decentralization ........................................................................................... 43 Sexual and Reproductive Health Policy ......................................................... 44 Challenges .......................................................................................................... 44 Interventions and Results .................................................................................... 44 Facilitating the Development and Formation of Networks and Coalitions from Civil Society ................................................................................... 45 Empowering the Network, Civil Society, and Community Organizations to Participate in the Policy Formulation Process ......................................... 46 Encouraging a More Participatory Process for the Identification and Analysis of Needs and Definition of Priorities in the Health Sector ......... 49 Creating Opportunities for Government and Civil Society to Interact at the Departmental Level ............................................................................... 49 Conclusion .......................................................................................................... 50 Chapter 6: Promoting Successful Participatory Decentralization: Lessons Learned from Policy Activities .................................................................................................. 53 Introduction ........................................................................................................ 54 Successful Practices ............................................................................................. 54 Summary ............................................................................................................ 58 References .............................................................................................................. 59 iv LATIN AMERICA & THE CARIBBEAN Foreword Much of the work undertaken by the USAID-supported POLICY Project in Latin America and the Caribbean (LAC) has been based on the premise that improving partnership between governments and civil society and strengthening participatory processes in the region can help improve the decentralization of the health sector. Working in Bolivia, Peru, Mexico, and Guatemala, the project has helped governments and civil society clarify their roles and strengthen decision making at the central, state, and municipal levels. The project has used its limited funds to intervene strategically to motivate citizens and build capacity of civil society organizations to participate as partners with governments in policymaking and governance and to convince government officials that sharing power and collaborating with civil society serves the interests of the country and its government. The POLICY Project’s overall goal in the LAC region has been to strengthen participatory processes as a means of creating a policy environment favorable to sexual and reproductive health. POLICY’s experiences in the region reflect differences in the degree to which governments have decentralized and the degree to which citizens are accustomed to participating in policymaking and civil society organizations. A common set of principles, however, has guided POLICY’s work over the past four years: v Work as partners with local counterparts, not in isolation from them. We respect and trust our counterparts and seek to earn their respect and trust in return. v Facilitate a process that enables counterparts to carry out an activity such as advocacy, policy dialogue, or research. In this way, we are cooperating in development of the region by creating an enabling environment for people to assist themselves. v Look for ways to create synergy, recognizing that projects have limited resources. We seek to add value to ongoing processes and bring together key people and organizations. Wherever possible, we leverage our resources by working collaboratively with local counterparts, donors, and other USAID collaborating agencies. v Start with listening to those who have a stake in the process. We educate ourselves and respect and respond to locally identified needs. v Bring skills and tools to a country, state, or municipality, but tailor the project’s approach to local needs, understanding that context and needs differ in each country (and even within regions of a country). This book represents the voices of project staff and local counterparts alike in telling the story of progress made in Latin America in forging national and local partnerships to promote sexual and reproductive health in the context of decentralization. Taly Valenzuela Participation Element Director and Regional Manager for Latin America and the Caribbean v Acknowledgments The idea for this book grew from a series of regional meetings at which participants recognized that their work presented a unique opportunity to showcase experience with a new form of policy change. Health Reform, Decentralization, and Participation in Latin America: Protecting Sexual and Reproductive Health summarizes POLICY’s experiences in implementing a participatory approach to decentralized planning in four Latin American countries: Bolivia, Guatemala, Mexico, and Peru. It is based on staff experience working in collaboration with dozens of NGOs and local governments to strengthen participatory decentralization. The POLICY Project acknowledges the members of the Latin American and the Caribbean team who so generously contributed their time and expertise to document the efforts of our local partners in the decentralization process. We would also like to acknowledge the continuous support and encouragement of our CTOs at the U.S. Agency for International Development (USAID): Elizabeth Schoenecker, Barbara Crane, and Mai Hijazi. The views expressed in this document, however, do not necessarily represent those of USAID. vi LATIN AMERICA & THE CARIBBEAN Contributors Martha Alfaro Evaluation Coordinator, POLICY Project/Mexico Sandra Alliaga Participation Coordinator, POLICY Project/Bolivia Mario Bronfman Executive Director, Center for Health Systems Research, National Institute for Public Health, Mexico Lilian Castañeda Participation Coordinator, POLICY Project/Guatemala Cindi Cisek Consultant Varuni Dayaratna Bolivia Country Manager, POLICY Project, The Futures Group International Edgar Gonzalez Long-term Advisor, POLICY Project/Mexico Francisco Hernández Planning and Decentralization Specialist, POLICY Project/Mexico Karen Hardee Research Director, POLICY Project, The Futures Group International Edita Herrera Participation Coordinator, POLICY Project/Peru Mary Kincaid Mexico Country Manager, POLICY Project, The Futures Group International Nancy McGirr Senior Technical Advisor, POLICY Project, The Futures Group International William McGreevey Planning and Finance Director, POLICY Project, The Futures Group International Lucia Merino Guatemala Country Manager, POLICY Project, The Futures Group International Mirna Montenegro Participation Coordinator, POLICY Project/Guatemala Patricia Mostajo Peru Country Manager, POLICY Project/Peru, The Futures Group International Beatriz Murillo Evaluation Coordinator, POLICY Project/Bolivia Charles Pedregal Planning Technical Advisor, POLICY Project/Bolivia Guido Pinto Long-term Advisor, POLICY Project/Bolivia Daly Salegio LAC Coordinator, POLICY Project, The Futures Group International Taly Valenzuela Participation Director, POLICY Project, CEDPA Ellen Wilson Paraguay Country Manager and LAC Evaluation Coordinator, POLICY Project, The Futures Group International vii CHAPTER 1 Promoting Partnership and Participation in the Context of Decentralization to Improve Sexual and Reproductive Health in Latin America and the Caribbean Kar en Hardee Karen Mario Br onfman Bronfman Taly Valenzuela Valenzuela William McGr eev McGreev ey eevey Introduction1 experience with decentralization and participation of civil society in the policy The International Conference on and planning process at the local level in the Population and Development (ICPD) urged LAC region, focusing primarily on the health nongovernmental organizations (NGOs) to sector. Chapters 2 through 5 discuss in work in partnership with governments to detail the POLICY Project's activities aimed implement the ambitious 20-year at fostering participation within a Programme of Action (United Nations, decentralized setting in Bolivia, Mexico, 1994). At the same time, it also challenged Peru, and Guatemala. Chapter 6 presents civil society to participate in policymaking, lessons learned from efforts to improve the program design, and implementation to policy environment for sexual and ensure that local health care needs, reproductive health through participation at including reproductive health needs, were the decentralized level within the LAC met. Many countries in Latin America and region. the Caribbean (LAC), as elsewhere in the world, are implementing the ICPD Government and Civil Programme of Action in the context of Society Partnership to health sector reform, which embraces a set of sweeping initiatives, including Implement the ICPD decentralization, theoretically designed to Programme of Action meet the health needs of communities In the years since the ICPD, most (Hardee and Smith, 2000; McGreevey, activities designed to promote civil 2000). The Programme of Action supported societies' role in implemenation of the ICPD the trend toward decentralization by agenda have occurred at the international recommending that governments promote and national levels. NGOs have gained community participation in reproductive increased legitimacy as formal health services by decentralizing the representatives of civil society capable of management of public health programs and working in partnership with governments to encouraging growth in the number of NGOs define reproductive health needs, design “Governments, in and private providers. The POLICY Project, policies, and implement and monitor collaboration with civil a five-year USAID-funded project launched programs (UNFPA, 1999a). In a 1998 UNFPA society…donors and the in 1995, incorporated the ICPD mandate to field inquiry, 13 of 23 countries in the LAC United Nations system, improve the policy environment for sexual region noted that they had taken measures to should…give high priority and reproductive health through involve civil society in implementing the to reproductive and sexual participation of civil society. Programme of Action, moreover, five of the health in the broader This chapter begins by presenting 23 countries in the region reported that they context of health sector experiences in the LAC region directed to had taken significant measures to strengthen reform.” promoting national partnerships of civil societies' ability to participate in policy (UN, 1999, Para. 52) governments and civil society to implement and program implementation (UNFPA, the ICPD Programme of Action. The 1999b). In eight of the 23 countries in the discussion sets the stage for a review of region, civil society has led major initiatives. In fact, countries such as Brazil, Chile, Colombia, and Peru, already had evolved a 1 strong advocacy community before the Cairo The authors would like to thank the following people for their assistance in preparing this chapter: Danielle Arigoni, ICPD. In countries such as Argentina, the Anna Britt-Coe, Nadine Burton, Harry Cross, Tom Goliber, advocacy community emerged or Cristina Herrera, Robert Hollister, Jodi Jacobson, Alan strengthened in preparation for Cairo while Johnston, Jeffrey Jordan, Mary Kincaid, Nancy McGirr, Tom Merrick, Priya Nanda, Guido Pinto, Susan Settergren, David in others it has developed since Cairo Valenzuela, Carlos Velez, and Ellen Wilson. (DAWN, 1999). 2 LATIN AMERICA & THE CARIBBEAN To strengthen their position since sexual and reproductive health. Cairo, groups have built broad alliances. In Nevertheless, initiatives at the international Argentina, for example, alliances of health and national levels can help pave the way for professionals, community members, and the participation at the local level.2 church have worked successfully in a highly conservative environment. In Brazil, the Decentralization National Council on Women's Rights was While policies and program direction revitalized in 1995 (Sadasivam, 1999). In often originate at the national level, Mexico, the National Forum of Women and reproductive health services are provided, Population Policy, a network of 70 Mexican though not necessarily administered, at the women's NGOs and academic institutions, local level. In a move to bring has worked to improve relations with the administration and direction of health (and government through its partnership efforts other) services closer to communities, many “Decentralization should (Bissel et al., 1998). Also in Mexico, the countries in the LAC region have turned to a not be viewed as a single National Safe Motherhood Committee has variety of mechanism to decentralize health act of giving up power from grown into a group of over 28 and other services. The expressed goals of the center to local representatives from the Senate, national decentralization (and broader health sector governments, nor should it public health institutions, UN agencies, reform) are to better meet local needs, be seen as a permanent NGOs, the media, and women's groups. improve the efficiency and quality of transfer of authority. Not Eight states now claim their own safe services, and ensure equity in health care. only do countries assign motherhood committees (Catino, 1999). In Decentralization involves the transfer different ranges of choice Peru, a group called the Tripartite Table, of decision-making power from a central over different functions, but established to follow through on the agency to peripheral agencies or subunits or these ranges of choice commitments made at the Cairo conference the delegation of functions formerly carried change over time.” and to address allegations that the out by central bureaucracies to government was coercing women into Bossert, 2000: 38 organizations distinct from the central sterilization, comprises representatives of government. Rondinelli (1981) offers the NGOs, donors, and government institutions. most widely used definitions of four types of Networks of civil society decentralization. Deconcentration gives organizations, such as the Latin American local areas greater responsibility within a and Caribbean Women's Health Network in sector, such as health. Through devolution, Brazil, Chile, Colombia, Nicaragua, and political power is transferred to autonomous Peru, are playing a role in monitoring regional or local authorities empowered with governments' progress in implementing the legal decision-making power and capable of Programme of Action. Their monitoring has generating and controlling financial and thus far revealed great difficulties in human resources. The agencies that including civil society and women in implement projects are responsible to local particular in the implementation process. or provincial governments rather than to The network has also pointed to several national ministries. Delegation involves the other deficiencies in the implementation of sexual and reproductive health activities (Bianco, 1998). 2 The POLICY Project is involved in promoting partnership The LAC region's agenda to promote and strengthening the capabilities of national NGOs in a partnerships between governments and civil number of countries around the world by strengthening and society at the international and national building networks, providing advocacy training and training of trainers, helping analyze the policy environment, assisting in levels is extremely ambitious. Little has organizing and conducting advocacy campaigns, distributing been done to promote participation of civil small grants to networks and NGOs, providing technical assistance, and promoting south-to-south exchange society at the decentralized level to improve (Valenzuela et al., 1997; POLICY, 2000). 3 transfer of some of a sector's accountability for the program and are implementation functions to semi- responsible for program evaluation. autonomous or semi-official entities that Representatives on the councils can include deliver a service. Privatization involves the elected community representatives, the transfer of property and administration of district health officer, the senior health services to nongovernmental entities, either nurse, the district administrator, hospital private or nonprofit. In practice, directors, representatives of NGOs, and decentralization in the LAC region, as departmental district heads from other elsewhere, is often "hybrid" in its sectors, including education, agriculture, implementation (Silverman, 1992), with and social services (WHO, 1994). combinations of types of decentralization in Many countries in the LAC region the same country, state, or sector alongside have made significant efforts to transfer “Effective decentralization functions that continue to be largely both authority and responsibility to local cannot rest simply on the centralized. authorities. Bolivia passed sweeping laws in transfer of authority, In the health sector, the most common 1994 and 1995 to decentralize both functions and resources type of decentralization is a combination of government decision making and financial from national to local deconcentration and devolution (Mills, control and to strengthen the participation authorities but must be 1994; Silverman, 1992; Bronfman, 1998). For of local communities in the public policy accompanied by a range of example, decentralization often entails process. Mexico began decentralizing its measures, including deconcentration to local governments health sector in 1982; the process was adequate training, designed associated with local teams of the Ministry interrupted between 1988 and 1994 and to support the newly of Health or devolution to mixed bodies completed in 1995–1996. The federal empowered localities.” such as local health committees, made up of government still provides most funding, but Forman and Ghosh, 1999: 17 both elected and assigned members. These local governments are responsible for mixed bodies can command wide powers planning and implementation to ensure that such as planning, implementation, control programs respond to local health needs. of human and financial resources, collection Peru promulgated a decentralization law in of some resources, and the promulgation of 1983; however, today the government some regulations, but they tend to remain remains highly centralized, particularly with under central control. Alternately, they can respect to setting standards, strategies, and hold narrow powers such as coordination budgets. In 1996, Guatemala revitalized its and transmission of information to the decentralization process and local center. Bossert (1998) characterizes the development councils with the signing of a range of powers and responsibilities as the peace accord, after 36 years of civil war. In decision space given to local governments Paraguay, decentralization was legislated on issues of finance, service organization, through the 1992 constitution. Since then, human resources, access rules, and decentralization of the health sector has governance rules. consisted of deconcentration of authority, The World Health Organization with an expanded role for the local (WHO) has advocated the use of district community in shaping programs. The health councils, which consist of a municipalities remain dependent on the combination of local representatives and central Ministry of Health for service health officials with managerial delivery, although with increased oversight responsibility in the area (Smith, 1997). The by local officials and citizens. Venezuela councils have both political and has devolved responsibility to its state administrative authority to determine health governments. Nicaragua has deconcentrated policy and approve district health budgets. power to the local health districts of the In addition, they have financial Ministry of Health. In Ecuador, 4 LATIN AMERICA & THE CARIBBEAN decentralization floundered due to lack of Politicians and bureaucrats often fear the commitment to implementation on the part loss of power and control implied by of the central government. decentralization. In practice, central Decentralization has economic and governments have transferred responsibility administrative facets, but the primary to local administrative levels for political motivation, regardless of the sector under reasons without proper planning and training decentralization, is political. Dillinger for implementation and without allocating (1994:1) has written that decentralization "is adequate resources or revising the necessary not a carefully designed sequence of legal and regulatory guidelines (Dillinger, reforms aimed at improving the efficiency of 1994; Kolehmainen-Aitken and Newbrander, public sector service delivery; it appears to 1997; Sadasivam, 1999). Decentralization be a reluctant and disorderly series of can simply reinforce local patronage systems concessions by central governments (Brinkerhoff, 2000). Case studies conducted attempting to maintain political stability." in several countries, including Mexico, Smith (1997: 409) adds, "Without doubt, found human and technical resources the most serious mistake any reformer can underdeveloped at local levels, which are make is to assume decentralization to be a generally incapable of providing reproductive “Depending on the policy managerial exercise devoid of political cause health services (Forman and Ghosh, 1999). conditions, decentralization and consequence." Writing about Latin Given that equity is often can give rise to either America, Bronfman (1998) notes that the compromised in the decentralization greater equity or inequity. processes of decentralization and process, a certain degree of centralization in In order to give rise to participation both occur within the political the health sector has proven necessary to equity, programs of system. The two processes are related but ensure equitable access to health care. decentralization have to be not always mutually reinforcing. In the LAC Inequity is exacerbated in countries with linked to policies on, for region, decentralization has been part of the wide regional disparities in resources and example, national health reform processes instituted by governments wealth (Vaughan et al., 1984; Knippenberg et planning, resource themselves rather than a response to al., 1997; Gilson, 1998; Collins et al., 2000; allocation, and community popular demand. Reforms have been Hardee and Smith, 2000). In writing about participation.” implemented in contexts where the potential one aspect of reproductive health, Abrantes Collins et al., 2000 for democratic participation was initially (1996) contends that the trend in Latin considered extremely limited. America toward universal coverage under Decentralization was introduced to counter health sector reform should benefit people "over-centralization," which has historically with HIV/AIDS by increasing their access to characterized the region (Apthorpe and health services. Urbina-Fuentes (1995) Conyers, 1982, in Bronfman, 1998). For counters that certain areas exhibit higher example, the populist politics of the 1930s concentrations of HIV/AIDS prevalence and through 1960s in Argentina, Brazil, and these must bear an unequal burden of Chile began as democratic revolutions but providing services to the affected group. In ended in strengthened, though often Chile and Colombia, Bossert (2000: 39) corrupt, central authority (McGreevey, found that the gap in per capita health 2000). expenditures between richer and poorer Stakeholders at the central and local municipalities seemed to be narrowing over levels in many Latin America countries have time, suggesting that "some improvements in found decentralization difficult to fully equity may have emerged under understand and successfully implement. decentralization in these two countries." 5 Participation of Participation, including that to promote sexual and reproductive health, can Civil Society at the take various forms, as shown in the box on Decentralized Level the following page. Civil society is now becoming a The role of civil society organizations stronger force in the LAC region. Politics (generally considered to include private, are more participatory both to avoid nonprofit organizations that pursue social criticism of centralized decisions and to welfare goals related to human rights, the increase the efficiency of governments in the environment, health, and women's rights) is face of decreasing resources and growing increasing as the role of government is demand (Tehranian, 1982; Bazdresch, 1997). diminishing. "In addition to providing ideas Participation, sometimes called democratic and suggestions for policy, civil society is governance, is justified as a means of expected to fill some of the gaps caused by promoting democracy and the exercise of government reduction of its traditional role “An informed and individual liberties (Brinkerhoff, 2000). In as provider of 'safety net' services" (Isaacs responsible public that addition, participation is considered a and Solimano 1999: 71). The role of civil demands quality sexual means to achieving efficiency in the society is growing increasingly important to and reproductive health implementation of local programs counter the trends of health sector reform care, and holds (Bronfman and Gleizer, 1994). through decentralization and globalization governments and facilities Barnett et al. (1997) provide a of health care in the region, which are accountable for providing it, framework for situating the role of exacerbating inequitable access to health is crucial for the effective participation in decentralization. They relate services. At a 1999 meeting of the Civil reform of existing services.” participation to decentralization through Society Forum of the Americas in Chile, Catino, 1999: 27 democratic local governance. The box below which was convened to examine the effects shows the role of civil society, through of health sector reform in the region, democratic local governance, in participants concluded that governments decentralization. should play a more active role in ensuring Figure 1 Decentralization Characteristics of Democratic Democratic Local Decentralization l Instituting constitutional and legal reforms to develop power to local structures (changes in relationships among levels of government) l Increasing local government’s ability to act (human and financial capacity and significant responsibility) l Increasing local government accountability, transparency, and responsiveness (changes in the relationship of government to citizens) Governance l Enhancing the role of civil society (individual and collective participation) l Improving the quality of life (citizens empowerment, service quality, and equitable access) Source: Barnett et al., 1997 6 LATIN AMERICA & THE CARIBBEAN Forms of Participation for Civil Types of Decentralization Society to Promote Sexual and that Promote Participation Reproductive Health at the Modes of decentralization have Decentralized Level implications for the ability of civil society to l Advocacy to influence decision making participate in decision making related to on national or local priorities and the program priorities and funding. priorities to be funded Deconcentration and delegation may not l Involvement in decision making by favor community participation, largely helping to set national or local because the authorities or agencies to whom priorities and make resource allocation or which the responsibilities are devolved decisions “Relatively stronger groups are not elected or assigned and therefore l Involvement in implementation will have louder voices, thus through NGO activities or networks, report to the central level rather than to the reducing the likelihood that client committees, and service delivery community. Bronfman (1998) writes that the needs of the poor will be l Involvement in oversight and devolution has the greatest potential for heard unless specific evaluation promoting participation, but it requires the measures are taken to l Sharing expertise with other locales operation of democratic processes at the assure that relatively and national coalitions of NGOs, local level. Deconcentration can promote disadvantaged and/or helping to replicate good programs at democracy, for example, district health marginalized groups’ local levels, or supporting local committees composed of workers assigned perspectives are taken into participation initiatives by the central ministry and of government account.” and NGO representatives drawn from the Brinkerhoff, 2000: 604 equitable access to health care and that civil community. The fact that some representatives society should actively promote equity in the are elected democratically and others are delivery of health care services (Isaacs and appointed creates a balance in reporting. Solimano, (1999). According to Gonzalo Sánchez de Lozada, Given the limits of communication former president of Bolivia, participatory within the political system, promoting the decentralization can work, provided that participation of all stakeholders in all strong local governments are created in decisions is a challenge (Smith, 1985). One partnership with civil society and that local specific problem is the inability of various areas are granted authority, particularly groups (organized or nonorganized civil authority over human and financial resources “The proposal that (Sánchez de Lozada, 2000). society organizations along with decentralized management representatives of the public sector, including Participation can exacerbate local of health care will be more legislators) to carry on political dialogue political factions and tensions. Smith (1997: responsible to local needs in since the groups use different codes of 409) notes that "participation is widely part depends on communication (Bronfman, 1998). How to recognized as a problem in poor countries decentralization being provide civil society with the capability to because of political inequality and accompanied by increased participate in political dialogue? Ideally, dependency, illiteracy, poverty, poor involvement by the public individuals should be able to put into communications, physical insecurity, catchment population in office officials who support their interests professional and bureaucratic hostility, some way in order to define (through the official circuit). Alternately, they political centralization and tokenism. those needs.” should be able to become organized around 'Communities' are not socially homogeneous Atkinson et al., 2000: 628 specific issues to advocate and/or pressure and the greater the inequality the more governments for change (through the difficult participation is likely to be. alternative circuit). "Having interests" is Programmes aimed at strengthening the unequally distributed and where it is not position of the poor may exacerbate guaranteed, elements must be introduced to conflicts with local and national elites, promote participation. which may have to be coopted before a 7 programme can run smoothly." In a study in prolong the decision-making process as all Italy, Putnam (1993) made an intriguing interested organizations are entitled to voice connection between decentralization and their position on an issue. The dilemma community participation. He found that the between participation and efficiency is that density of civic institutions (for example, the smaller the community chosen, the choral societies and soccer clubs), which he greater the potential for participation but termed "social capital," predicted improved the greater the degree of participation, the performance of local government. The more greater the potential for inefficiency and social organizations in an area, the better lack of coordination. Often, countries the performance of local governments. choose the provincial or state level for Bossert (1998: 1516), extending the analysis decentralization and then seek mechanisms to health care, writes "This approach to promote participation in smaller “We [the government of suggests that those localities with long and communities (Mills et al., 1990). Bolivia] didn’t give deep histories of strongly established civic Furthermore, not all civil society communities authority. We organizations will have better performing organizations promote participation. didn’t allow them to hire decentralized governments than localities Brinkerhoff (2000) writes that the and fire teachers, health which lack these networks of associations. assumption that civil society organizations workers, and others. The In Colombia, anecdotal cases suggest that are by nature participatory is not always local communities should some regions, such as Antioguia and Valle, true. He notes that "some civil society have the right themselves. might have more dense social networks, organizations are exclusionary and They can better observe which might explain why they have better authoritarian" (p. 609). Speaking about his how the work is being performing institutions." Atkinson et al. government's experience in promoting completed…and a vital (2000) agree that to understand participatory decentralization, past connection of responsibility decentralization fully and recognize why it president Sánchez de Lozada of Bolivia and authority will be succeeds in some areas rather than in (2000) noted that he learned to distrust established.” others, it is important to understand the NGOs that did not have a "territorial" Sánchez de Lozada, 2000 effects of local social organization and (regional or community) base because such political culture on the reform process. NGOs are not accountable and their own Smith (1997: 403) writes that agendas can overshadow their work. multisectoral decentralization seems to be Still, participation can help promote necessary for the promotion of community successful decentralization. Panama participation. Reviewing a survey conducted established village-level health committees by Rifkin (1986) of 200 primary health care in the 1970s to share responsibility with the projects, Smith noted that "programmes that Ministry of Health for planning, sought to promote only health and health- implementation, and evaluation of health “Opening up the policy related services actually limited community programs. An evaluation of the village process to more participation because health is not health committee system showed that while participation rarely necessarily a top priority, lay people see over 90 percent of the committees were proceeds smoothly or little scope for their own involvement, and inactive by 1983, several factors, including without serious conflicts, professional planners tend to define the active local participation, led to success backsliding, and politico- problems and present communities with the among the other 10 percent (Smith, 1997: bureaucratic game- solutions. Participation in which people 405). Thus, decentralization of health playing.” bear responsibility rather than just reap services was most successful when civil Brinkerhoff, 2000: 609 benefits is effective when a range of society participated in its implementation at community needs is being addressed." the local level. Participation does not always result in The effects of decentralization and an improvement in efficiency at the participation on the provision of health care, decentralized level; in fact, participation can including reproductive health, are not clear. 8 LATIN AMERICA & THE CARIBBEAN Bossert (2000) concluded in his study of partnerships with civil society as a means of decentralization in Chile, Colombia, and implementing the ICPD Programme of Boliva that decentralization yields mixed Action. results, with indications of increased equity The challenges facing partnerships at but no indication of major changes in the international and national level in performance. A study group at WHO (1996: improving sexual and reproductive health 61) noted that "empirical evidence suggests are likewise relevant at the decentralized that greater caution should be used in level. Indeed, McGreevey (2000) notes that estimating gains. In Mexico, regional a central dilemma in the decentralization of disparities have heightened; in Latin health services is that it requires political America, there have been increases in the decentralization to ensure its full influence of dominant groups…." Aitken effectiveness. Several countries in the LAC “In the case of Brazil, the (1999: 124) contends, "Where resources are region remain highly centralized; yet two main reform strategies scarce, new health problems and challenges, realization of the benefits of are to increase space for such as reproductive health, are particularly decentralization requires not only the local autonomy and local threatened under a decentralized system." voice…. The processes by With little data disaggregated by sex, which these strategies are particularly at the decentralized level, it is assumed to transform into Recommendations to difficult to say if women are at a disadvantage greater empowerment, Promote Partnership with in terms of access to and utilization of accountability, Civil Society to Implement the services, although indications suggest that responsiveness and quality ICPD Programme of Action they are. Decentralization can lead to local of health care are priorities that fail to reflect the needs of All governments should adopt measures to moderated at every point by women–and, by extension, children–because facilitate the involvement of civil society the local social organization women are often excluded in the decision- in the formulation, implementation, and political culture in making and priority-setting processes. monitoring, and evaluation of policies, which the local health strategies, and programs by system is embedded.” l creating common forums for dialogue; Atkinson et al., 2000: 631 Continued Challenges to l reexamining concepts, assumptions, Promoting Partnership agendas, priorities; l listening to and respecting the and Participation experiences of other partners; While governments have increasingly l identifying and building on the included civil society in the policymaking comparative strengths of various partners and using existing and program implementation processes, relationships; participation generally has been limited to l identifying key issues, players, and the national level. Therefore, to ensure that institutions; all stakeholders participate in promoting l developing mutual accountability and sexual and reproductive health policies and transparency among partners; programs, governments, civil society l developing joint plans of action at organizations, donors, and technical various levels; assistance projects such as the POLICY l strengthening capacities at all levels and Project share a continued challenge to ensuring sustainability; promote partnership and participation at the l encouraging coalition building and international, national and decentralized networking; and levels. The following box lists the l continuing to monitor implementation recommendations that emerged from a 1998 of the Programme of Action. roundtable meeting on the importance of Source: UNFPA, 1998 9 ceding of greater functions to lower levels of that can be detected in power relationships government but also the institution of (especially the empowerment of formerly electoral accountability, local revenue- marginalized groups) can serve as indicators raising capacity, and the involvement of of effective participation. local community groups and NGOs in The four case studies in the following decision making and implementation chapters illustrate participation in the (Birdsall and Haggard, 2000). These context of decentralization in Bolivia, changes are more than just administrative. Mexico, Peru, and Guatemala, as well as the They involve a local replication of the POLICY Project's role in facilitating national process of democratization, participatory policy and planning processes. including the formation of responsible and The case studies highlight the activities accountable governments, the formation of undertaken by the POLICY Project to local party organizations that can recruit promote participation at the decentralized leaders and politicians, and the level, the unique challenges faced by the institutionalization of accountable and project in each country, and the extraordinary transparent government. These are clearly results achieved by counterparts given the long-term tasks, but they are likely to be tools and skills available to empower them advanced by the development of local civil to participate in shaping local agendas to society groups. meet their needs. It is still too soon to Substantial effort will be needed to assess the impact of civil society strengthen the capabilities of local participation on sexual and reproductive stakeholders to participate at the health outcomes at the decentralized level; decentralized level. Some observers contend however, we contend that engaging civil that the level of participation is evidence of society in defining its own needs is an whether a process is effectively important outcome in itself. The following decentralizing (Fuenzalida, 1993; Cabrero chapters, while not formal evaluations, and Lira, 1992; Collins and Green, 1994; provide evidence of the value of promoting Gawryszewski, 1993; Bronfman, 1998). participatory policy processes that empower Nevertheless, many decentralization civil society, particularly women who have policies that claim to include participation not often been heard in the past, to be part are not in fact designed to promote it, even of the local decision-making process-both when they imply some degree of transfer of defining their own health needs (including responsibilities from the center to the reproductive health) and seeking the means periphery (Barnett et al., 1997). The changes of meeting those needs. 10 CHAPTER 2 Bolivia Case Study Guido Pinto Sandra Alliag Alliagaa Varuni Day aratna Dayaratna Charles PPedr edreg edreg al egal Beatriz Murillo Introduction Context The Bolivia case study illustrates a Geographic, Social, and process for ensuring that civil society Economic groups have the opportunities and skills needed to participate effectively in Bolivia is a landlocked country decentralized decision making. In a country situated in the middle of South America. It where an explicit law mandates popular has a population of 8 million, 63 percent of participation in decentralization, it is whom reside in urban areas. Urban reasonable to expect that citizen populations are concentrated primarily in involvement in local decision-making the departments of La Paz, Cochabamba, processes is a matter of routine. However, and Santa Cruz, whose capital cities, until when local communities are unaware of the recently, received the largest share of the responsibilities that laws impose on them country’s financial resources. Similarly, and when they lack the skills necessary to health, education, and other social services participate in policy processes, are concentrated in these urban areas. decentralization fails to be participatory Bolivia’s rural population of over 3 million even amid a favorable legal and institutional lives far removed from the country’s climate. Bolivia faces such a situation, epicenters of political and economic power. especially in its peripheral municipalities Rural residents rarely participate in political where large portions of the country’s rural decision-making processes and have little and poor populations reside. access to social services. Forty-two percent This chapter describes efforts to of Bolivia’s rural inhabitants are indigenous, realize the true potential of Bolivia’s namely, Aymará, Quechua, and Tupi- Popular Participation and Decentralization Guarani. laws. The overarching approach was to A low per capita income ($1,000) and inform citizens of their rights and a highly inequitable income distribution responsibilities under the two laws and to render Bolivia one of South America’s provide them with skills and knowledge in poorest countries. Over 40 percent of urban the areas of planning, advocacy, and families and 92 percent of rural families live leadership so that they could translate those below the poverty line. One-fifth of the laws into action. Within the context of population is illiterate; however, the rate is participatory decentralization, efforts worse in rural areas, where illiteracy is 36 concentrated on working with civil society percent overall, and 49 percent among rural groups and municipal governments to bring women. community sexual and reproductive health Similar patterns are reflected in health needs to the forefront of local agendas. and reproductive health conditions. These approaches would ensure that Although Bolivia has seen considerable decentralization paved the way for joint improvement in its sexual and reproductive decision making whereby civil society and health status during the past decade, it still local governments together developed lags behind in the Latin America region and policies and programs that responded significant rural-urban disparities exist directly to community needs, particularly in within the country. Bolivia’s total fertility the area of sexual and reproductive health. rate is 4.2, 50 percent above the regional average. Fertility among rural women is almost twice as high as that of their urban counterparts. Less than half of married women use contraception, and only 32 12 BOLIVIA percent in urban areas and 11 percent in rural councils, and indigenous organizations. The areas use modern methods. Skilled law empowered OTBs to participate actively attendants assist with 60 percent of births, in local decision making and thereby ensure but the maternal mortality rate, at 390 per that plans and policies reflect local needs; 100,000 live births, is among the highest in oversee the implementation of these plans the region. Maternal mortality in rural areas and policies; and monitor municipal is almost double that of urban settings. governments to ascertain that resources are spent in a transparent and effective manner. Through the OTBs, local communities for Decentralization and the first time had the opportunity to give Participation: A Favorable voice to their concerns, shape local Legal Climate agendas, and ensure that municipal funds were used to address community needs. In 1994 and 1995, the government of Bolivia passed two groundbreaking laws that significantly transformed Bolivian society. Sexual and Reproductive The laws were intended to further Health Policy: A Changing democratization in Bolivia by bringing local communities into the public policy process. Landscape, 1970–2000 The Popular Participation Law (PPL) of 1994 Between 1970 and 2000, the and the Administrative Decentralization Law government’s attitude toward sexual and (ADL) of 1995 laid the foundation for a reproductive health changed from hostile political, institutional, and legal framework intolerance to active support. In the early that transferred decision making and 1970s, Peace Corps volunteers were financial control to local governments, and expelled from Bolivia for allegedly gave citizens the legal right and sterilizing rural women without their responsibility to participate actively in this consent; ProFamilia’s family planning clinics decentralization process. were closed down; and a ministerial decree The ADL transferred many central eliminated the family planning component government functions to Bolivia’s nine of the Ministry of Health’s (MOH’s) maternal departments. Most important, it gave and child health program. Despite the departmental governments control over adverse policy conditions of the 1970s, human resource management. The PPL, on private clinics made timid efforts to provide the other hand, strengthened the powers of contraceptives to the well-to-do while some Bolivia’s 316 municipalities through several NGOs attempted to serve low-income mechanisms. First, the central government clients (Olave, 2000). guaranteed municipalities an equitable, Between the 1980s and 2000, health population-based share of tax revenues. policy in Bolivia evolved slowly, moving Within this system, the Department of from an exclusive focus on child survival Treasury distributed one-fifth of total tax and safe motherhood to the reinstatement of revenues among local governments. Second, family planning as a priority and, eventually, the central government transferred control of to a broadened perspective on sexual and all social and cultural service infrastructure reproductive health consistent with the 1994 (e.g., health, education, and sports) to ICPD agenda. In 1989, the Bolivian municipal governments. Finally, the PPL gave government established the National legal recognition to civil society Program on Reproductive Health to ensure organizations called Base Territorial that the work of different institutions and Organizations (OTBs), which include citizen agencies, both public and private, are oversight committees, neighborhood coordinated and complementary. The 13 program has evolved into today’s National v Third, neither local communities nor Forum for Sexual and Reproductive Health. authorities viewed sexual and As a result, sexual and reproductive reproductive health issues as priorities health is now an important component of that merit local-led policy attention. The Bolivia’s development and poverty alleviation support for reproductive health programs efforts. As such, it receives attention in at the central level had yet to trickle programs and policies at the national level. down to subnational levels, where The current administration has included problems associated with the economy, sexual and reproductive health and women’s agriculture, education, and epidemics health priorities in its Strategic Plan for such as malaria take precedence, Health. Also in place is a Basic Health especially in the minds of men, who have Insurance Scheme (initiated under the traditionally controlled policy processes. previous government and expanded by the v Finally, vocal advocates who could propel current one) designed to cover infant, sexual and reproductive health to the maternal, and child health care; the forefront of municipal agendas were few diagnosis and treatment of sexually and far between. Although more aware of transmitted diseases (except HIV/AIDS); and sexual and reproductive health problems family planning. than their male counterparts, many Bolivian women consider high maternal and infant mortality rates, chronic Challenges reproductive health problems, unwanted pregnancies, and domestic violence part Despite a political and legal of “normal” life and something beyond environment favorable to both participatory their control. Therefore, they are rarely decentralization and sexual and reproductive vocal in advocating for change. However, health, several factors have impeded citizen ignorance about reproductive rights is participation in policymaking at the only part of the reason for women’s decentralized level, particularly with respect passivity. Cultural constraints and lack of to sexual and reproductive health. confidence, advocacy skills, and v First, local communities were unfamiliar leadership models play an equally with the content of the PPL and ADL and important role in keeping women from hence unaware of their rights and taking advantage of opportunities to responsibilities vis-à-vis local decision identify and prioritize their needs in local Learning to Participate making. Thus, they voiced little demand planning processes. in Remote Areas of for entry into policy and planning Bolivia processes. v Second, citizens lacked the skills Interventions and Results “This is the first time that necessary to participate effectively in Recognizing the above challenges technicians from the policy processes, particularly populations and taking into consideration department level and high- that have habitually been marginalized recommendations from local counterparts, level officials from La Paz and excluded from decision making, the program in Bolivia focused on the have visited this forgotten namely, rural populations, women, and following goal: to support and facilitate the village.” indigenous groups. In addition, local improvement of sexual and reproductive [President of a neighborhood governments lacked the administrative health by ensuring that decentralized association in Exaltación] capacity, technical skills, and political decision making is participatory as will to translate laws into action, often envisioned in the laws and that local plans tending to favor party needs over and policies respond to community sexual community needs. 14 BOLIVIA and reproductive health needs. Within this designed to ensure that participants were context, the strategy has been to aware of their rights and responsibilities v inform citizens of their rights and under the PPL; knew how to exercise those obligations under the PPL and ADL and rights in the municipal planning process; to provide them with the skills and and understood the importance of knowledge necessary to participate in the integrating community sexual and decentralization process; reproductive health needs into local plans. Over 450 women and men attended the v raise awareness among both community workshops. They were affiliated with Base members and policymakers about sexual Territorial Organizations, Neighborhood and reproductive health problems, their Vigilance Committees, indigenous groups, impacts, and means of addressing them local NGOs, women’s groups, youth groups, in the policy arena; and and local governments. v strengthen civil society groups and Participants hailed from notably grassroots organizations so that they can different socioeconomic backgrounds; they become effective advocates for sexual had different levels of education, and some and reproductive health. were illiterate. Few were familiar with the contents of the Popular Participation and Administrative Decentralization laws. Many Making Municipal Planning had never participated in local decision- Processes Participatory making processes; those who had done so Many municipalities receive little, if were accustomed to a confrontational any, attention from the outside world. approach of making demands regardless of Making local decision making more their impact and feasibility. Each of these participatory for remote municipalities with realities posed a challenge to effective and large indigenous and rural populations cooperative participation. involved a multifaceted approach. Working The workshops sought to address with the Vice Ministry of Popular these challenges. They began with a Participation, the approach consisted of presentation and discussion of the laws to training workshops, extensive follow-on lay out clearly the role of civil society vis-à- technical assistance in developing municipal vis the municipal government in decision development plans (PDMs), and making. Using participatory training preplanning workshops to raise awareness methods that engaged participants in about sexual and reproductive health and debates and discussions, facilitators covered reproductive rights among prospective a large amount of ground in three days. participants in the planning process. Participants reviewed data on the health, sexual and reproductive health, education, and economic status of their municipality; Training workshops they learned to use the information to The first step involved conducting identify problems and their causes; they three-day participatory planning workshops identified strategies and projects for in 11 municipalities between May and addressing key community needs and December 1998.1 The workshops were problems; and they prioritized strategies on the basis of financial, political, and cultural viability. In short, by using examples, 1 Riberalta, Trinidad, Exaltacion, Santa Ana, Magdalena, exercises, and actual data on sexual and Baures, and Huacaraje in the department of Beni; Oruro in the reproductive health, participants walked department of Oruro, Cobija in the department of Pando, Comarapa in the department of Santa Cruz, and La Paz. through the various stages of a planning 15 activity, learning how to participate Gender and sexual and reproductive effectively in a pivotal municipal decision- health workshops making process. In the process, they also One-day workshops on gender and learned about the health and sexual and sexual and reproductive health for reproductive health status of their community members—men and women who municipalities. were prospective participants in the municipal planning process—complemented the ongoing technical assistance. The Continued technical assistance workshops were designed to provide Following the workshops, local information and raise awareness about authorities in six of the 11 municipalities gender and sexual and reproductive health received continued assistance during issues as well as to provide a forum for formulation of their PDMs. The participants to reflect on their reproductive municipalities were Riberalta, Trinidad, rights and reproductive health status, often Exaltación, Santa Ana, Comarapa, and for the first time. The ultimate goal of the Cobija. With the exception of Cobija and workshops was to help ensure that PDMs Comarapa, the municipalities belong to the demonstrated gender sensitivity, reflected department of Beni. The period of PDM the needs of women, and addressed formulation provided the opportunity to community sexual and reproductive health ensure that PDMs were developed in a needs. Indeed, following the workshops, participatory manner, based on data, and many participants decided that sexual and gender-sensitive, and responsive to reproductive health programs should be a community-articulated sexual and priority for their communities and reproductive health needs. subsequently worked to include them in Throughout the municipal planning their municipal plans. process, it was necessary to work closely As a result of the training workshops, with the Population Policy Unit (UPP) of the continued technical assistance, and Ministry of Sustainable Development to awareness raising about sexual and disseminate to municipalities and reproductive health—all within the departments data and information on local framework of decentralized participatory sexual and reproductive health status. In planning, the PDMs of Riberalta, Trinidad, 1998, under a newly launched Modems-to- Exaltación, Santa Ana, Comarapa, and Municipalities Program,2 50 municipalities Cobija included, for the first time, programs received modems and training in their use, and funding for sexual and reproductive providing access to population databases health. For example, the PDM of Santa Ana from the MOH, Vice Ministry of Popular included three such programs: a training Participation, UPP, and the census bureau. program for teachers, health personnel, and Thus, with some technical assistance, local NGO staff; an information, education and authorities and community representatives communication (IEC) program for sexual in target municipalities were able to use the and reproductive health; and the creation of data to highlight and prioritize community municipal office for women’s affairs. By sexual and reproductive health needs during contrast, the PDM of the neighboring the formulation of PDMs. municipality of San Borja, which received no external assistance in participatory processes, neither included nor made any reference to sexual and reproductive health. 2 Sponsored by the POLICY Project and the Ministry of Sustainable Development. 16 BOLIVIA Building a Cadre of Leaders between March and November 1998. The and Advocates for Sexual and leadership workshops took place the Reproductive Health following year between July and November; 132 women, many of them alumnae from the To create core groups of advocates for advocacy workshops, participated. In each women’s issues, including sexual and department, an established and well- reproductive health, throughout the country, regarded local women’s NGO cosponsored participatory planning efforts were extended the training workshop. These NGOs in 1997 by working with the Coordinadora continue to be responsible for the continuity Nacional de la Mujer (CNM), an established and sustainability of the processes started in network of women’s NGOs. CNM was the nine departments of La Paz, Oruro, undertaking an ambitious project to provide Potosí, Cochabamba, Chuquisaca, Tarija, women in leadership positions with the Beni, Pando, and Santa Cruz. skills necessary to become active participants in policy processes. The project Four Days Go a Long developed three training modules in Supporting Advocacy for Way: Causing a Ripple political participation, advocacy, and Gender and Sexual and Effect in Beni leadership. Each module consisted of one Reproductive Health Issues: national-level training-of-trainers (TOT) workshop for CNM representatives from From Skills-Building to Following a 4-day advocacy- different departments and subsequent Action training workshop in Riberalta, a municipality replica training workshops in Bolivia’s nine Supplementary funds in the form of with 698,710 inhabitants, departments. CNM members who small grants provided opportunities for local the women of Riberalta participated in the TOT served as co- women to use their advocacy skills to mobilized and on June 21, facilitators in the department-level promote gender equity and sexual and 1998 created the Casa de la workshops, expertly demonstrating their reproductive health in their communities. Mujer/Riberalta, an entity newly acquired skills. Workshop participants accessed grants after whose objective is to advocate The advocacy and leadership preparing proposals to replicate advocacy for and advance the workshops were designed to provide training workshops and/or carry out empowerment of women, participants, who were primarily women, advocacy activities of their own. with a focus on sexual and with the knowledge and skills necessary to In Sucre, during the 1999 elections, reproductive health. During become effective participants in local women from the Centro Juana Azurday used the following year, members decision-making processes. Participants a small grant to work with youth groups and of Riberalta’s Casa de la learned about political structures and implement a series of advocacy activities Mujer worked with processes that they must deal with as designed to convince candidates to counterparts in the advocates for women’s rights and issues; incorporate sexual and reproductive health neighboring municipality of effective advocacy techniques, including issues, particularly concerning the needs of Guayaramarin, providing how to develop compelling messages, target adolescents and youth, into their election them with advocacy and audiences, organize campaigns, and use platform. In Riberalta, the Casa de la Mujer gender training, as well as data in advocacy efforts; and concepts and used a grant to lobby members of the Vaca the guidance necessary to techniques of leadership. The leadership Diez Consumer Cooperative to donate a create an equivalent Casa de workshops included a component on the building, thereby allowing the organization la Mujer in Guayaramarin. municipal planning process to ensure that to establish a stable presence in the On May 5, 1999, the participants know when and how to use their community. Recipients used a portion of the Guayaramarin Casa de la new skills during the formulation of PDMs. grant to develop brochures and organize Mujer opened its doors. Almost 200 participants, virtually all meetings to educate the community about of them women, participated in the the need for community-based family advocacy workshops, which took place planning and reproductive health programs. 17 Members of the Santa Cruz Casa de la In the rural community of Achacachi, A Gender Office in El Mujer used a grant to lobby the municipal findings from another study on the impact Torno, Santa Cruz government successfully for the creation of of the Popular Participation Law on women’s municipal Gender Office. These are but a participation in decision making showed the Women from the Casa de la few examples of how women’s groups in marginalization of women in community Mujer/Santa Cruz used Bolivia used grants to translate their decision making, particularly with respect to small a grant to convince newfound advocacy and leadership skills sexual and reproductive health. The study municipal officials of the need into concrete actions and results. also identified sociocultural issues, the for an office within the predominance of traditional gender roles, municipal structure devoted and male dominance in society as the Collecting and Using factors contributing to such marginalization. to women’s issues. Grant recipients initiated their Information at the Local The results of such studies have advocacy activities by Level demonstrated to community members and collecting information on the policymakers alike the need to emphasize In the past five years in Bolivia, forms and functions Gender sexual and reproductive health and gender several research activities, most of them Offices elsewhere in Bolivia, issues in planning, policy formulation, and pilot endeavors at the department level, as well as the structure of the advocacy. provided crucial information that ultimately Municipality of El Torno. influenced policy decisions and program They conducted one-on-one development. For example, in 1998, findings from a survey-based study of adolescent Conclusion meetings and workshops with sexual and reproductive health behavior and municipal officials and Efforts to improve civil society attitudes were presented to and endorsed by community representatives to participation in decentralized decision- department leaders. The results were making processes in Bolivia involved forging raise awareness on the subsequently incorporated into a pilot partnerships with civil society organizations, importance of gender sexual and reproductive health education community leaders, and municipal officials sensitivity and women’s program in six local high schools. The and building their capacity and willingness participation in municipal department of Chuquisaca allocated to work together to ensure that municipal planning processes. Together additional resources in the form of six staff plans and policies would truly reflect and with community leaders, they members to this activity. respond to the needs of the population. developed a proposal for the Also in 1998, a study in Oruro Through a combination of awareness creation of a Gender Office in identified factors that interfere with the raising, training, technical assistance, and El Torno. Finally, they delivery of sexual and reproductive health small grants, hundreds of citizens lobbied and negotiated with services at the local level. The survey-based throughout the country have built new skill the municipal council to make study delved into the knowledge and bases. They are better able to lead, this proposal a reality. Their attitudes of the local population toward advocate for their needs, and participate in advocacy efforts were sexual and reproductive health and the public arena, thus fulfilling the roles and successful. In July 1999, the addressed access to and coverage of sexual responsibilities laid out for them in the decentralization and participation laws. Gender Office of El Torno and reproductive health in Oruro. The was officially inaugurated findings pointed to a pervasive lack of Through informed and effective knowledge and information about sexual and with the mandate to participation at the decentralized level, civil reproductive health problems and care guarantee a gender focus in society groups have achieved much. In the options and an apparent mismatch between all municipal policies, a municipalities of Riberalta, Exaltación, and the supply and demand for sexual and Santa Ana and the departments of Beni, municipal program to educate reproductive health services. The results of Potosí, and Santa Cruz, to name just a few, the population on their sexual the study were disseminated and used in civil society groups are successfully using and reproductive health participatory planning workshops at the their new skills not only to identify and rights, and a budget to municipal level. voice their concerns about sexual and implement these activities. 18 BOLIVIA reproductive health and gender issues but municipalities, communities and municipal also to create entities and participate in officials who received training in decision-making processes that will allow participatory planning and gender/sexual them to address those concerns. In and reproductive health workshops worked Riberalta and Guayaramarin, local women together to include, for the first time, sexual came together to create Casas de la Mujer, and reproductive health programs in their centers whose objective is to empower five-year municipal plans. Thus, with women and to work toward improving their training and technical assistance, civil reproductive rights. In Santa Cruz, women society groups in Bolivia have been able to advocates successfully lobbied the surmount many of the challenges to municipal government to establish within participation in decentralized decision the official municipal structures an office making and have gradually formed a network devoted to gender issues. In the department of advocates with the skills and commitment of Chuquisaca, six high schools introduced necessary to keep sexual and reproductive sexual and reproductive health education health at the forefront of local agendas. programs in their curriculum. In six 19 CHAPTER 3 Mexico Case Study Martha Alfaro Alfaro ar Gonzalez Edgar Edg Francisco Hernandez Mary Kincaid Introduction and the effectiveness of their advocacy and related activities. The long-term vision for the The Mexico case study describes a planning groups is that they will serve as participatory methodology for multisectoral permanent policy advisory boards in the strategic planning at the state level in the states, helping to guide the formulation of context of a decentralized health sector. state policies on HIV/AIDS prevention and Decentralization of the health sector provides treatment as well as the coordination of Mexico’s states with the opportunity for programs across sectors. improved targeting of financial resources according to local needs. In the case of HIV/ AIDS, however, it also carries the risk that Context local policymakers will decide not to provide funding for HIV/AIDS programs in the state. Geographic, Social, and In particular, HIV/AIDS prevention and Economic treatment are not included as part of the federally mandated basic package of health Mexico is a diverse country of nearly services. 100 million inhabitants, including an estimated 8.7 million indigenous people The program described in this chapter (INI, 1999) concentrated in largely rural attempted to reach out to multiple sectors in areas and in the southern region bordering selected states to increase participation in the Guatemala. The 32 states, including the policymaking process for HIV/AIDS at the Federal District of Mexico City, range in state level. The goal was to improve planning population from 375,000 in Baja California and coordination and to build sustainable Sur to 11.7 million in the state of Mexico, partnerships among NGOs and public sector which surrounds the Federal District. The organizations already involved in HIV/AIDS as country had a total of 2,426 municipalities well as to attract new organizations to the in 1999. Approximately 22 percent of the fight against HIV/AIDS, including the population lives in rural areas (PAHO, education and tourism sectors, churches, 1998), and many communities in the universities, and indigenous organizations. mountainous areas of both the east and west The principal approach was to carry out are difficult to reach by road, leaving their background research at the state level on the inhabitants economically and socially policy environment for HIV/AIDS (AIDS isolated. With both a thriving economy and Policy Environment Score), the main income from oil production, Mexico is stakeholders, the current state of the relatively well off economically. The average epidemic (situation analysis), and the per capita income in this middle-income response of the government and others to the country was US$4,180 in 1999, but epidemic (response analysis). The research inequities abound and almost one-fourth of phase was followed by week-long strategic the population still lives in extreme poverty. planning workshops with representatives from the key sectors, with the objective of forming Access to health care facilities is multisectoral planning groups with workshop considered adequate for most of the participants. The final stage of the approach population, with the public sector serving 51 was to provide follow-on technical assistance percent of residents nationwide (Saavedra, and training to the planning groups, at their 2000) either through the social security request, to ensure the sustainability of the system hospitals and primary care centers or groups, the quality of their strategic plans, public facilities for the uninsured. 22 MEXICO Decentralization and HIV/AIDS Policy: Participation Preventing the Spread of the Responding to requests from the states Pandemic that they be allowed to plan, budget, Mexico has an HIV prevalence rate execute, and allocate resources to their own estimated at about 0.5 percent, which is programs, Mexico accelerated the similar to that in the United States. Through decentralization of its health sector under the mid-1990s, the epidemic was largely the Health System Reform Program (1995– limited to men who have sex with men. 2000). In 1996, the Health Secretariat signed Several states, however, now face a growing the two agreements: the National Agreement epidemic as tourism and circular migration for the Decentralization of Health Services, from Central America and the United States and the Agreements for Coordination for the spread HIV to new populations, including Complete Decentralization of Health rural populations, indigenous groups, and Services. These agreements establish a women. Poverty, low literacy rates, and the framework that allows federal entities to low status of women compound the operate autonomously in the states, identify problem. The ratio of male to female AIDS priorities in relation to health care services cases in the state of Mexico, a largely rural at a local level, and commit the state to “sending” state, is 5:1 compared with 9:1 in participating and taking responsibility at the nearby Mexico City, with heterosexual municipal level. The decentralization transmission accounting for one-third of movement was reinforced in 1997 through cases registered by risk factor2 in the state reforms to the National Health Law and the (Ramirez, 2000). An estimated 40 percent Social Security (IMSS) Law and with of HIV-positive persons do not have access presidential decrees regarding “New to trained care providers, and only an Federalism” and “Decentralized Public estimated 30 percent have access to Institutions.” While the federal government antiretrovirals, which are essential for is still the main source of funding, state survival and for improving the quality of governments and local elected officials are infected persons’ lives (Saavedra and Uribe, now responsible for local planning and 2000). program implementation and for ensuring In 1996, the National AIDS Council that resources respond to local health needs. (CONASIDA) developed a four-year plan Increasingly, the role of the HIV/AIDS/ (1997–2000)—as part of the Ministry of 1 STI coordinator in each state is to address Health’s decentralization plan—to transfer the impact of and opportunities associated several of its functions to the state level. with the decentralization of services and to Under the new plan, the states were made build partnerships among organizations responsible for the following activities and working in HIV/AIDS and STI. services: v coordination among public, private, and social sectors in the HIV/AIDS area; 1 Throughout this chapter, the reader will see references to both HIV/AIDS and HIV/AIDS/STI programs, reflecting the recent integration of the HIV/AIDS and STI programs at the state level in Mexico. The integrated approach has not been 2 adopted by many of the NGOs working in HIV/AIDS; “Risk factor” refers to the category of behavior or exposure subsequently, many of the references in this case study are to to HIV reported by the infected person. Factors include men HIV/AIDS, not to HIV/AIDS/STI. When a program specifically who have sex with men, intravenous drug use, unprotected sex addresses STI as well as HIV/AIDS, the authors have used the (i.e., without a condom) with multiple sexual partners, and term HIV/AIDS/STI. blood transfusions, among other factors. 23 v development of norms in collaboration states, and local policymakers are frequently with each state’s Commission on Human prejudiced against individuals with HIV. In Rights; fact, they often deny the extent to which HIV/AIDS affects their local communities. v development and dissemination of While CONASIDA formed state-level AIDS educational materials tailored to the local councils (COESIDAS), the councils in many context and culture to inform citizens states have been inactive such that about means of transmission and methods responsibility for state activities has fallen of preventing HIV; to the State Coordinator for HIV/AIDS. v programs targeted to high-risk groups; Typically, the state HIV/AIDS coordinators v training for health care personnel to have no direct budget control, and therefore improve the quality of medical and social are limited in their efforts to comply with services provided to HIV-infected CONASIDA’s four-year plan and to carry out persons; programs designated as the responsibility of the states. v oversight of implementation of and adherence to the national norms for A further challenge comes from the prevention and control of HIV/AIDS lack of community involvement and within the state’s health care system; and coordination in many high-risk states. Although Mexico City has seen a vigorous v establishment of a telephone hotline and sustained, albeit often uncoordinated, service with local access to provide response to HIV/AIDS from the NGO information and referrals to the public community (nearly 70 NGOs work on the about HIV/AIDS. issue), such is not the case throughout Mexico. In states such as Yucatan and Guerrero, the NGO community is much less Challenges active on the issue: in those areas, between With the decentralization of the health three and five NGOs work on HIV/AIDS sector, each State Health Secretariat is now issues. These and other high-risk states also charged with developing its own plans and face a lack of coordination on HIV/AIDS budgets for presentation to its respective programs within the NGO community; state legislature. The legislature can then between the public and private sectors; and approve or amend the plans and budgets. across sectors such as health, education, Mexico’s decentralization offers an tourism, and indigenous affairs. opportunity for states to develop programs that are more responsive to the needs of their populations; however, it also carries the Interventions and Results risk that political interests and limited Since 1998 and in response to knowledge of technical issues on the part of CONASIDA’s mandate to strengthen state-level decision makers may lead to decentralization, POLICY developed a pilot decisions that fail to serve the interests of strategic planning program to foster the the local population. The concern for development of multisectoral state planning responsible, decentralized governance is groups for HIV/AIDS. In the first two years, particularly acute with respect to HIV/AIDS the project focused its work in the states of because many state officials have little Guerrero, Yucatan, and Mexico and in the understanding of the disease. Furthermore, Federal District (Mexico City). In early conservative Catholic Church leaders exert a 2000, the team initiated activities in the strong influence over local politics in some states of Oaxaca and Vera Cruz. 24 MEXICO Developing a Participatory identify potential participants in the Planning Approach to HIV/ strategic process; measuring the AIDS AIDS at the State Level Policy Environment Score4 through the application of a survey to approximately 25 Around the time the program was key informants in each state; and holding a starting in Mexico, UNAIDS released a new press conference held by state leaders and series of manuals to guide developing the head of CONASIDA to announce the counties’ strategic planning efforts in HIV/ start of activities and to invite the state’s AIDS. The manuals, designed to “help plan media to participate in the process. The and manage a broad response to HIV, with adaptation of the UNAIDS methodology contributions from all sectors of society” continued over a two-year period. (UNAIDS, 1997), were intended for use with Responding to requests from participants at a national strategic planning committee for the end of the first two workshops, the team country-level planning. The project team3 developed a new component that called for reviewed the manuals and modified the providing substantial, continued assistance planning methodology to promote enhanced to the planning groups after their formation. participation in the planning process. In Each step of the process—from initial addition, the team adapted the methodology interviews and data collection to the for use at the individual state level. The workshops and follow-on assistance—was strategy focused on forming groups carefully designed to incorporate a composed of a broad range of state and local participatory approach. The local experts organizations already working in HIV/AIDS who prepared the situation and response and related fields and collaborating with analysis spent much of their time in face-to- them to develop an integrated strategic plan face interviews with key informants in the for HIV/AIDS that would address the needs states to ensure that the collected of the states’ vulnerable populations. information was current and accurate. At the The original UNAIDS approach state level in particular, written sources of included four steps: an analysis of the information are weak or nonexistent, making situation, analysis of the response, strategic field visits all the more important. The team plan formulation, and resource mobilization. sent drafts of the situation and response Before the start of any strategic planning analysis reports to the respondents to activities in the selected state, some validate the information and repeated the preparatory steps ensured broad-based process with participants at the strategic support for the process and a thorough planning workshops. The workshop design understanding of the policy environment and itself included minimal presentation formats to reach out sought involvement of those working in related fields. The steps included dialogue with and/or lobbying the State Secretary of Health to gain support for opening the planning and policy process to participation from civil society; conducting a 4 The AIDS Policy Environment Score (APES) is a composite score for measuring change in the policy environment over comprehensive stakeholder analysis to time in a country and, in some cases, across countries. The APES is distinct from the situation analysis and response analysis reports, both of which are part of the UNAIDS strategic planning methodology. The APES is used primarily for evaluating the impact of the entire POLICY program in Mexico while the situation and response analyses are 3 The POLICY Project team for Mexico consisted of Mexican elements of the strategic planning process in each state. They and U.S.-based project staff as well as local Mexican expert provide the basis for much of the work carried out by consultants and advisors who provided additional guidance participants in the week-long planning workshops and in the and input to the program. planning groups thereafter. 25 In a speech in Acapulco in and focused instead on participant coverage and as a way to involve journalists August 1999, Dr. Patricia discussions and small group work, letting as participants in the planning process. The Uribe, the Coordinator the group determine the eventual outcomes most interesting experience so far has General of CONASIDA, of the workshop (i.e., form a multisectoral occurred in the state of Guerrero, where two commented on the assistance planning group, develop a strategic plan, well-known journalists joined the planning provided to CONASIDA take a different course of action, or nothing group and succeeded in dramatically and the states. In particular, at all). increasing coverage of HIV/AIDS in the she commended the local state. Clips from the evening television team for having “the news on TVAzteca/Guerrero, the most flexibility and creativity to Journalists as Allies and popular station, feature interviews with undertake the modifications Participants policymakers, physicians, and social workers necessary [to work] in each involved in HIV/AIDS issues; relevant different locale.” From the outset, one of the principal statistics about the epidemic in the state; She continued, “The strategies in Mexico was to involve interviews with persons living with HIV/ POLICY Project has journalists and the media in the program AIDS who speak about the social isolation, contributed to the process of both as allies to help build political and discrimination, and poverty they have decentralization and public support and as participants in the endured since falling ill; and interviews with strengthening the strategic planning process itself. The people on the streets of Acapulco asking interaction between key approach was simple and low-cost but about prevention methods, why they think actors in each community highly effective. After gaining approval from prevention campaigns do not work, and where it has worked. Apart local authorities to start work in a particular other relevant issues. The two journalists from the hoped-for results state, the team and/or State HIV/AIDS also convinced colleagues who host weekly from the collaboration with Coordinator for AIDS invited local talk shows to invite members of the POLICY, we had several journalists, television stations, and multisectoral planning group onto their areas of value added from newspapers to attend a press conference shows, gaining valuable exposure for the the project: where the state Secretary of Health and the group’s work and bringing much-needed l empowerment of the state Coordinator General of CONASIDA would airtime to the HIV/AIDS issues in a socially HIV/AIDS program announce the start of the planning initiative conservative state. The sustained interest of coordinators; for HIV/AIDS in that state. The press these media representatives and their l awareness raising and conferences served several other purposes: involvement with the planning groups is an motivation of personnel to educate media representatives about HIV/ excellent example of how journalists can be in the field; AIDS, to convince them to increase effective advocates for a social issue as well l improved coordination coverage of the issues and in an unbiased as part of the solution and how they can use and relations among manner, and to attract at least one journalist their communication skills to expand the participants in the to attend the strategic planning workshop discussion on controversial topics such as process; and and become part of the state’s multisectoral HIV/AIDS. l deepening of the planning planning group. An attractive press kit included up-to-date information on HIV/ process to involve AIDS-related issues, such as condom use operations personnel Bringing Key Actors from the primary level.” and its effectiveness in HIV/AIDS/STI prevention, human rights and HIV/AIDS, Together to Forge Alliances and statistics and other information about and Develop a Multisectoral the epidemic in the state and country. It Plan also provided contact information so that Results of the stakeholder analysis interested journalists could interview state identified participants for attendance at a or federal HIV/AIDS experts and keep week-long state-level strategic planning abreast of the planning initiative. workshop. State leaders reviewed the list The strategy worked well in terms of and usually added other names and both increased quality and quantity of media institutions. As a result, the workshops drew 26 MEXICO an average of 30 participants per state. To guide the group through an inevitable date, workshops have been held in Yucatan, period of conflict during the first few days Guerrero, and the state of Mexico. The of the workshop to help ensure that workshops included presentations on the participants would eventually accept each situation and response analyses in that other’s differences, learn about the work of particular state; training in strategic others in the area of HIV/AIDS, and develop planning methods; presentations and the mutual trust and respect that is a exercises on thematic topics of relevance, necessary precursor to collaboration. including human rights, gender, and men In Guerrero, Yucatan, and Mexico, who have sex with men; and small group where so few state and local organizations sessions intended to rank the issues and are working on HIV/AIDS, it was crucial that needs in each state and to identify strategies most of these organizations decided to join for addressing the issues. At the end of the planning group and that new each workshop, the participants agreed to organizations joined with them to fight the form groups that would continue to meet to disease. The groups, two of which are well coordinate activities, share expertise, and into their second year of existence, have the develop a common strategic plan for HIV/ potential to influence state-level policies on AIDS in their respective state. HIV/AIDS across multiple sectors and to Even though workshop participants make a difference in the course of the agreed to form planning groups and tackle disease in their communities. The goal is to the issues of HIV/AIDS in a coordinated help the planning groups achieve sufficient fashion in their states, the outcome was not credibility among policymakers so that they a given. Workshop participants had to eventually become a permanent advisory overcome prejudices against each other and/ group offering a coordinated response to or their organizations as related to sexual HIV/AIDS and thus serving state orientation, political affiliation, institutional government, the private sector, and civil policies, and other issues. To reach the society organizations in their communities. decision to work as a group, many factors had to come together. For example, rival NGOs had to put aside past differences; the Helping to Sustain the State public and NGO sectors had to get beyond Planning Groups a tradition of mutual dislike for the other’s As requested by the planning group, approach; and Catholic priests had to the strategy in Mexico has included engage in dialogue with outspoken continued assistance and training on group representatives of the gay community. In structure and organization, conflict addition, some workshop participants had to resolution, strategic planning, technical be convinced of the value of a participatory aspects of HIV/AIDS, and review and planning process and the wisdom of comment on the strategic plans developed involving representatives from other sectors by the groups. The multisectoral planning in developing strategies that affect how the process has allowed the groups to carry out health or education sector, for example, a comprehensive analysis of HIV/AIDS tackles a crosscutting issue such as HIV/ needs in each state, the overall resources AIDS. Similarly, some public sector available to address needs, and the representatives had to be convinced of the appropriate role of the various stakeholders value of listening to the recommendations in optimizing the use of available resources. of an NGO about which actions are most appropriately the province of state In the states of Guerrero and Yucatan, institutions. In short, facilitators had to the planning groups spent almost one year 27 Constructing Spaces for developing their strategic plans; they are v The traditional enmity between Dialogue on HIV/AIDS devoting much of the second year to the government institutions and NGOs in Guerrero approval process. In Guerrero, the group working in HIV/AIDS has dissipated in was slowed down initially by a lack of the state of Guerrero. Since the creation In his keynote address to the training in strategic planning techniques. of a multisectoral planning group in that Mexico National AIDS Much of the technical assistance provided state in 1998, the state Secretariat of Congress in November to CEMPRAVIH (Coordinación Estatal Health and the NGO community have 1999, Dr. Roberto Tapia, Multisectorialde Prevención y Atención en jointly developed a strategic plan that Under Secretary of Health, VIH/SIDA) during 1999 was geared toward encompasses the health, education, and stressed the need to building skills in planning techniques. In tourism sectors; conducted local IEC construct spaces for dialogue Yucatan, planning group members initially campaigns and events to raise awareness, between the public sector, directed much of their energy to awareness including substantial coverage of HIV/ civil society, and persons raising and policy dialogue activities, AIDS in the state through state and living with HIV/AIDS and reacting to the immediate needs they national television news; and reached out to find new forms of identified in the strategic planning to the state’s large indigenous population participation. He promised workshop. Although this approach delayed with the first local-language educational that the Federal Secretary of progress on the strategic plan itself, it materials. Health would continue to provided group members with an v A recent internal evaluation (Wilson, strengthen the state HIV/ opportunity to work through various 2000) of the work in Guerrero stated, “It AIDS programs to broaden conflicts that arose (common to most is clear from talking to respondents that the response to multiple groups in the formative stages) and to reach having a coordinating group has sectors and to reach out to all agreement on what they would eventually significantly strengthened and improved regions of the country. include in the strategic plan. Therefore, the the response to HIV/AIDS in the state of Noting that the national technical assistance requested by the Guerrero in a variety of ways. The congress this year was being Yucatan group was a combination of training primary impacts of this multisectoral held in the state of Guerrero, and speakers on thematic topics, skills group as perceived by the participants are Dr. de la Fuente took the building in group formation techniques and improved coordination, a change in their opportunity to applaud the conflict resolution, and, finally, help in own perspectives that has altered the way efforts of CEMPRAVIH, refining their strategic plan and they work within their own institutions, the state’s multisectoral accompanying dissemination/approval and the creation of new programs planning group: “One of the strategy. In the state of Mexico, the devoted to HIV/AIDS.” principal reasons the state of planning group is still in its first months of Guerrero was asked to host existence, although its strategic plan is v The Yucatan planning group is working to gain approval for its strategic plan from this conference is because it expected to come together relatively quickly. is an example of a state-level The group left the workshop with a well- the various public and private sector organizations identified in the plan. The program that has developed outline of problems, strategies, significantly improved in the and priority areas. state Secretariat of Education and of Tourism as well as the state’s NGO last few years, community and CONASIDA have demonstrating a great endorsed the plan, which was presented political commitment and Outcomes to the new State Secretary of Health in creating a multisectoral Multisectoral planning in Mexico has June 2000 for approval. During the past group for the fight against yielded impressive results. two years, the group has carried out a HIV/AIDS, which includes broad range of advocacy and educational the state Secretary of v In the states of Yucatan and Guerrero, activities, including a training course for Education, the state where the planning groups have been 120 health care providers. The group Commission on Human functioning for nearly two years, diverse obtained funding for the five-day course Rights and civil society groups such as the Catholic Church and from 22 sources, including the state and organizations.” gay rights advocates have come together to work on the issue of HIV/AIDS. federal governments, private sector 28 MEXICO Changing Attitudes among Health Care Providers and the Public in Yucatán Asked about the impact of their work in the state, three members of the Yucatan planning group offer their own observations and experiences since joining the group. l “In one of my volunteer trips to the hospital to visit HIV patients, the nurses were wearing masks to enter that section and even asked visitors to do the same to avoid getting infected. One of the nurses offered a mask to me to wear, and I responded, “I know what I am here for,” showing her the red bow. On subsequent visits, I observed that none of the nurses was wearing a mask to enter the HIV patient area.” — Q.F.B. Adriana Berzunza Coello, Member of the Yucatan GMC l “I have noticed that HIV+ patients in the [local facilities of the] Mexican Social Security Institute now speak about their ailments with more confidence. In other words, the moral prejudice among care providers has diminished, and as a result, the doctor can offer better care, something that did not happen in the past. This is solely the result of the information health care providers have received recently about HIV/AIDS.” — Dr. Salomon Gallegos, Member of the Yucatan GMC l Jose Manuel Polanco, a member of the Multisectoral Citizen’s Group of Yucatan, spoke about one of his experiences from a workshop the Yucatan GMC conducted with students in their last semester at a teacher training school (1999). According to Jose Manuel, the students were very receptive to the topic, and, at the end, one of them suggested that to lend more realism and enrichment to their learning experience, someone with the AIDS virus should speak to the class about living with the disease and the problems that person faces on a daily basis. Upon hearing the suggestion, Jose Manuel responded, “In fact, you have spent a week with a person living with HIV; I have the AIDS virus.” His announcement was met with much emotion and achieved a great deal of sensitivity among the students for the problem. companies (such as Coca Cola, Glaxo State Secretary of Health credited the Wellcome, and many local businesses); planning group, CEMPRAVIH, with and NGOs. Most recently, members influencing the decision to increase successfully advocated for state funding funding for HIV/AIDS/STI. of a local laboratory and clinic capable of v In the Federal District, where no state HIV/AIDS testing and treatment in AIDS program existed, local advocacy accordance with federal guidelines for efforts called for the creation of a district treatment of HIV+ patients. government program to address HIV/ v Advocacy by the planning groups in both AIDS. As a result, in February 2000, the Yucatan and Guerrero has resulted in an Federal District government opened the increased line item for HIV/AIDS/STI in offices of the HIV/AIDS Council for the the 2000 annual state budgets. This is Federal District (CODFSIDA). The the first time state funds (2 million CODFSIDA includes representatives from pesos) in Yucatan have been allocated a broad range of private and public specifically to HIV/AIDS/STI. This year’s organizations, civil society, and sectors budget in Guerrero includes a 6 percent such as education, health, tourism, and increase for HIV/AIDS/STI. The Guerrero others. It has also initiated a multisectoral strategic planning process. 29 Conclusion represents a substantial achievement in light of decentralization of the health sector and In sum, the support provided to HIV/ the lack of federal requirements for state- AIDS stakeholders in the targeted states has level funding of HIV/AIDS programs. The strengthened public/private sector state planning groups’ efforts to finalize and coordination, helped build partnerships gain approval for their multisectoral among diverse organizations, and attracted strategic plans also demonstrate their new organizations to the fight against HIV/ commitment to making decentralization AIDS in Mexico. In the states of Guerrero work on the ground. By coordinating their and Yucatan and in the Federal District, the efforts and leveraging resources, they can approach has improved the policy help ensure that HIV/AIDS receives environment for HIV/AIDS, as evidenced by adequate attention in their states, despite the increase in resources allocated to conservative political and social interests prevention and services in 2000. This that would prefer to ignore the disease. 30 CHAPTER 4 Peru Case Study Ellen Wilson Patricia Mostajo Edita Herr era Herrera Introduction Context The Peru case study offers an example Geographic, Social, and of enhancing participation at the local level Economic in a country that has so far decentralized to only a limited degree. It also demonstrates Peru is a heterogeneous country both the ability to achieve nationwide impact at geographically and culturally. It has three the local level through an alliance with a distinct geographic regions (coast, decentralized network of women’s mountains, and jungle). Its population of 25 organizations with branches in all of Peru’s million is unevenly distributed, with 72 25 departments. percent residing in urban areas, primarily in Local governments have the potential the coastal region. Political and economic to develop reproductive health programs power is concentrated in the capital, Lima, that are responsive to the needs of local which alone counts a population of 7 communities. However, this potential is million. Culturally, Peru has a large frequently not realized due to several indigenous population,1 and it is estimated challenges that are similar to those in the that 7 million Peruvians maintain their other countries studied: local leaders’ native language, primarily Quechua or limited understanding of reproductive health Aymara. issues, civil society’s weak advocacy skills, Significant disparities in standard of and the public sector’s lack of recognition living, income, and access to services are of the value of civil society participation. In apparent. Nationally, the illiteracy rate is 8 Peru, the strategy was to build the advocacy percent, but it masks substantial differences skills of local women’s groups through a based on gender and regions. Illiteracy tiered advocacy training program and to among women is three times higher than provide technical and financial assistance to among men, and in the departments of the group to design and carry out advocacy Ayacucho, Huancavelica, and Apurímac, campaigns in support of sexual and illiteracy rates are more than four times the reproductive health. national average (between 33 and 37 Traditionally in Peru, civil society percent). High poverty levels are one of the participation in health programs has meant most dramatic signs of inequality in Peru. that civil society groups are encouraged to Although the proportion has decreased collaborate in campaigns developed by the since 1991, half of the population still lives Ministry of Health and to support its in poverty, and 4.5 million Peruvians (27 policies. A more active form of participation percent of the population) live in conditions encourages civil society to act as an equal of extreme poverty. The proportion of partner with government representatives, people living in poverty is higher in rural working together to identify problems and areas, although, in absolute numbers, more to develop and implement solutions. In people live in poverty in urban areas. community after community, groups have Health statistics are similarly variable. successfully mobilized the support of Infant mortality in rural areas (62 per 1,000 municipal councils for reproductive health live births) is more than double the rate in programs, motivated government officials to urban areas (30 per 1,000). In Lima, more establish new reproductive health programs, and established mechanisms such as Citizen Oversight Committees for ongoing 1 According to the Census of Native Communities, there are partnerships between civil society and local seven Andean ethnic groups and 65 Amazonian ethnic government. groups, although the latter represent less the 4 percent of Peru’s native population. 32 PERU than 90 percent of births are attended by interpretation or implementation of sectoral trained health personnel, but less than 40 policies has been the responsibility of the percent of births are attended by trained local offices of executive ministries (such as health personnel in the mountain and jungle regional health offices). In 1999, however, regions. Limited access to care contributes to President Alberto Fujimori proposed that Peru’s high maternal mortality rate, which is local governments expand their roles by estimated at 265 maternal deaths per assuming responsibility for managing 100,000 live births. Fertility is relatively low services in the health and education sectors. in Lima and the rest of the coast (2.5 and Despite attempts at decentralization, 2.9) but much higher in the mountain and the government of Peru remains highly jungle regions (4.6 and 4.7, respectively). centralized. The CTARs have little power, Use of modern contraception is 41 percent and no progress has been made on the overall; it is over 40 percent in all regions proposal to assign the management of except the mountains, where it is 29 percent. health and education services to local Traditional methods of contraception are governments. Some officials in the Ministry used by over 20 percent of women in union of Health resist the transfer of authority in both urban and rural areas. because they believe that local governments are ill equipped to take on responsibility for health care and would need extensive Decentralization and training before they could do so effectively. Participation Nevertheless, the government has According to its constitution, Peru is made some efforts to promote community a unitary state divided into 24 departments participation in the management of services (plus one constitutional province), 188 at the grassroots level. In 548 communities, provinces, and 1,808 districts. In 1998, the the Ministry of Health has created Local government of Peru enacted a Health Administration Committees (CLASs) decentralization law creating Transitory composed of community representatives and Regional Administration Councils (CTARs) local health personnel. In practice, however, at the departmental level. The CTARs are this type of participation asks civil society responsible for administering the funds representatives to help the Ministry of assigned to the department and Health carry out its campaigns and support coordinating the execution of sectoral its programs. The committees have little policies. The councils have little autonomy, opportunity to propose their own initiatives however, and are not representative of the or to work with the Ministry as equal local population. Specifically, they are partners to identify problems and develop attached to the Ministry of the Presidency, solutions. In addition, each CLAS focuses and council presidents are not elected but on a small community, and therefore does rather assigned by the executive branch. The not provide an opportunity to influence decision-making power of the councils is health programs in larger municipalities or limited to making adjustments within the in regions as a whole. budgetary and policy frameworks previously determined at the central level. In contrast, authorities at the Sexual and Reproductive provincial and municipal levels are elected Health Policy by the local population from among local Since President Fujimori came to candidates. Traditionally, provincial and power in 1990, the central government has municipal governments have limited their strongly supported sexual and reproductive role to urban development while the health programs, particularly family 33 planning. The government has placed understanding of the needs of the particular emphasis on increasing access to communities with which they work. family planning services in response to As a result of the criticism and to unmet need. As part of this effort, in 1995 prevent further abuses, the Ministry of the Congress modified the National Health instituted safeguards in February Population Law to legalize surgical 1998 to ensure that women would be able to sterilization as a family planning method, make free and informed choice. The making the service available for the first Ministry of Health solicited input from time to many women who wished to limit various public and private institutions, and family size. In the same year, the Ministry of it incorporated that input into modifications Health began offering free family planning to the National Reproductive Health and services in an attempt to eliminate financial Family Planning Program and the Manual of barriers to contraceptive use. Standards and Procedures for Voluntary In 1997, however, the government Surgical Contraception Procedures. These family planning program came under sharp modifications include improved counseling, criticism. Many NGOs and other civil a waiting period before the sterilization society groups felt that the program procedure, and close monitoring of generally emphasized quantity of services sterilization practices. The Ministry also over quality and did not respect the rights of informed health workers that there are no clients to a free and informed choice of targets for sterilization. Finally, it has begun contraceptive methods. The strongest to work more closely with NGOs to help criticism was related to sterilization. Civil design programs that respond to client society organizations, including the Catholic needs, monitor the implementation of those Church and many NGOs, accused the programs, and train ministry personnel in government of setting targets for the issues related to client rights, reproductive number of sterilizations doctors had to rights, and gender awareness. perform. They also cited cases of women who were pressured into sterilization against their will as well as a number of botched Challenges sterilizations that led to health problems While both decentralization and and even death. effective collaboration between government Various factors in program design and civil society hold potential for the contributed to the problems, including development and implementation of sexual v the lack of mechanisms to ensure the and reproductive health programs that are quality of sterilization services; more responsive to the needs of local v local health authorities’ lack of communities, several obstacles prevented understanding of reproductive rights and realization of such potential. client rights; and v Local elected officials demonstrated little v inadequacy of monitoring mechanisms understanding of sexual and reproductive and lack of indicators related to quality health issues and were unaware of needs and gender. in their communities. Partially as a result, they did not consider that they The Ministry of Health has recognized had a role to play in improving the sexual that the flaws resulted in part from a design and reproductive health of their process that was not participatory—civil constituents. society organizations were not given an opportunity to provide input based on their v Civil society groups lacked the skills to participate effectively in decision-making 34 PERU processes related to policies and departments. A significant advantage of programs intended to improve women’s working with the RNPM was that its status, particularly with respect to sexual nationwide presence permitted the provision and reproductive health. Specifically, they of training in tiers to eventually achieve an could not identify community needs, impact at the decentralized level throughout develop effective strategies, and present the country. Training began with a training- their ideas convincingly to local of-trainers for 25 women representing 16 authorities. different departments (representatives of the v Local authorities in the Ministry of remaining nine departments were trained in Health and other sectors did not 1999). Courses focused on sexual and recognize the value of civil society reproductive health policies and issues, participation, and few opportunities advocacy skills, and training methodologies. existed for collaboration between Following the workshops, participants authorities and civil society returned to their departments and trained representatives. over 500 people on the same themes highlighted at the decentralized level. The departmental workshops included not only Interventions and Results community leaders and representatives of NGOs but also representatives of the Beginning in 1997, the response to the ministries of Health and Education and local above challenges involved strengthening the government. By involving representatives of capacity of civil society groups to the public sector in the workshops, the participate in decision-making processes, RNPM was able to enlist the various engage local authorities, and mobilize local representatives as allies to help them reach elected officials to address sexual and key decision makers, such as the regional reproductive health needs. In most directors of ministries, mayors, and the community participation efforts, civil society heads of regional councils. groups merely help government agents Advocacy facilitators benefitted from implement their programs. The broader continuous support, including annual concept of participation envisions civil update workshops to relay information about society working as equal participants with new policies, to share experiences, and to government agents to design, implement, develop and coordinate strategies. In this and evaluate programs to meet the needs of way, each department updates its annual their communities. In order for civil society plans based on changes in the context, groups to be able to influence programs in prioritization of themes, and appearance of their communities, they would need training new stakeholders. to gain an in-depth knowledge of the situation, strong technical and advocacy skills, and an opportunity to apply the skills Putting Lessons into Practice they have learned. Following the training, each departmental branch of the RNPM received Building Skills at the financial and technical support to develop Decentralized Level advocacy campaigns related to sexual and reproductive health, violence against The National Network for the women, and political participation and Promotion of Women (RNPM) is a citizenship. Each of the departments decentralized, democratic network of organized forums to generate dialogue on women’s organizations with bases in all 25 these themes and to develop proposals to 35 increase awareness and improve services. sexual and reproductive health, coordinating Among the 16 departments, close to 1,000 with government officials to improve people participated in each of three forums. services, working with the media to increase Supplemental funds in the form of awareness and generate support, and minigrants enabled six departments during running for political office. the first year and 21 departments during the second year to carry out advocacy Involving local elected leaders campaigns on selected themes. The Many activities have focused on opportunity to apply the newly learned municipal governments, encouraging them advocacy techniques was crucial in helping to expand the scope of their activities to the groups consolidate their new skills. A include sexual and reproductive health. As a representative of one group said, “When you result, other municipalities are for the first participate in a workshop and you don’t put time addressing the sexual and reproductive what you learned into practice, you forget, health of their communities. One example no?” All groups drew heavily on their new comes from the department of Ayacucho, skills in the design and implementation of where a branch of the RNPM, in alliance their campaigns, including with the NGO COTMA, used a range of v needs assessment; strategies to win the support and v identification of primary and secondary commitment of local elected leaders for audiences; sexual and reproductive health programs. v identification of key messages and The Ayacucho RNPM began by forming an channels; alliance with a local radio station that aired a series of programs highlighting women’s v forging of alliances; health and sexual and reproductive rights v facilitation of meetings; and the importance of women’s participation v analysis and effective presentation of in local and national development. The data; and programs helped raise public awareness of and interest in these topics in advance of a v policy dialogue. symposium held on March 6, 1999. The The advocacy campaigns have not only symposium was specifically designed to helped the groups further develop their address newly elected municipal advocacy skills, but they have also achieved councilwomen and to win their support for significant results, including the official placing women’s issues on the municipal commitment of local authorities to address agenda. The RNPM took advantage of the issues, the development of proposals to several facilitating factors to help broaden improve municipal policies, the formation of the scope of the local government’s agenda. intersectoral committees, and the First, ever since President Fujimori establishment of ongoing collaborative proposed the expansion of municipal relationships between local authorities and responsibilities to include the management civil society representatives such as citizen of health and education services, local oversight committees. governments have been eager to expand their roles in these areas. Second, the newly elected councilwomen were still looking for Achieving Results an agenda to promote, and the RNPM was The advocacy campaigns employed a able to help them not only with the issues few key strategies that called for involving they could support, but also the information local elected leaders in programs related to and skills to address the issues effectively. 36 PERU The symposium began with governments, the RNPM has been working presentations by several former with local government officials, particularly councilwomen who shared their experiences in the ministries of Health and Education, to in municipal management, particularly in improve policy and program relation to the themes of violence against implementation. One example of women, women’s health, and the promotion collaboration is the creation of citizen of sexual and reproductive rights. By oversight committees. presenting the work of grassroots social In May 1998, a Symposium on Citizen organizations, the symposium also sought Oversight for Healthy and Safe Motherhood to increase the councilwomen’s appreciation conceived the concept of citizen oversight is for the work of local civil society “an attitude of ongoing commitment, organizations and the potential for effective participation and awareness to create collaboration. At the end of the symposium, change in favor of my community and participants agreed to form a Network of influence decision makers so that policies Councilwomen of Ayacucho and pledged to and their application are truly to our develop a strategic plan to incorporate benefit.” As a result of the symposium, the women’s issues into the municipal agendas. RNPM received a donation from USAID to As part of that effort, they will count on carry out a pilot project to form citizen organizations such as the RNPM for oversight committees in three departments. technical assistance. Thus, the One year later, a national forum on sexual councilwomen gain influence and participate and reproductive rights concluded that the more effectively in their municipal councils RNPM should extend the formation of as a consequence of the technical and committees to all of Peru’s departments in political support they receive from the response to the emerging controversy over women’s organizations, while the women’s voluntary surgical contraception. organizations gain valuable allies in the government who will promote policy El Callao, the constitutional province changes in favor of women. of Peru, is one political subdivision where a citizen oversight committee has been Other branches of the RNPM have created. The local branch of the RNPM been interested in the strategy employed in organized a forum on March 8, 1999, on Ayacucho and are implementing similar sexual and reproductive rights. The campaigns. Sponsoring study tours to objective was to generate dialogue between Ayacucho is one means for other RNPM civil society organizations and local Ministry branches to learn how to replicate of Health authorities and to develop Ayacucho’s successful experience. For proposals regarding the application of example, a team from Amazonas had the policies favorable to sexual and reproductive opportunity to meet with councilwomen rights. The regional Ministry of Health from various municipalities and learn how officer, health care providers, local they are incorporating the themes of women government officials, and representatives of and reproductive health into the municipal grassroots community organizations agenda. attended the forum. Speakers presented information on the sexual rights of women, Coordinating with government free choice of family planning methods, and officials to improve policy the experiences of communal work, thus implementation demonstrating the importance of citizen participation for effective implementation of In addition to promoting sexual and sexual and reproductive health policies. As reproductive health on the agendas of local a result of the dialogue initiated at the 37 forums, the regional health officer endorsed however, the policy has been slow to be the creation of a citizen oversight implemented nationwide. In 12 departments, committee that will work jointly with the branches of the RNPM have been working to departmental Ministry of Health to monitor raise awareness of the issue and to generate and improve health services. The director the political will to take action to improve also committed to respect sexual and programs in part through effective use of the reproductive rights and to provide high- media. One example is the department of quality services in a nurturing environment. Moquequa, where the local branch of the A year later, three more committees RNPM and the Institute of Women and the have been formed in El Callao, and all of Family carried out a campaign to raise the committees continue to meet monthly. awareness among educators and parents of Committee members are drawn from the need for appropriate and timely grassroots organizations such as community information for adolescents on sexual and kitchens, “mothers’ clubs,” and “glass of reproductive rights. The groups began by milk organizations.” The Ministry of Health interviewing education authorities in several has supported the committees by provinces throughout the department to distributing the standards of care as gather information about adolescents’ sexual parameters for the oversight they should and reproductive needs. They then compiled exercise. The committees have focused on the information into a motivational packet monitoring pregnant women and collecting for local officials and developed a pamphlet information on the women’s perceptions of entitled “Breaking the Silence” for available health services. adolescents and the media. To generate broad-based support for the campaign, the This model for civil society groups carried out several interviews on participation is now being applied local radio stations in the period leading up nationwide. Currently, citizen oversight to a three-day workshop from September 27 committees are operating in 11 of Peru’s to 29, 1999. Coordinators, specialists, departments, and the United Nations directors, and teachers from the Ministry of Population Fund is supporting similar Education attended the workshop, during initiatives in the remaining departments. which participants developed an action plan to initiate sex education activities in the Working with the media schools. The media again supported the campaign by disseminating the One of RNPM’s successful strategies commitments made by the authorities. As a has been to forge alliances with the local result of the campaign, participants have media to increase awareness of sexual and repeated the workshop in their schools to reproductive health issues and to hold local raise the awareness of other educators. In authorities accountable to the public. The addition, one school has initiated a alliances have been much easier to establish counseling program, and another has at the decentralized level than they would formed an Adolescent Defense Committee. be at the central level, where the media generally have their own agenda. In most cases, collaboration with the Running for office media has been part of a larger advocacy The advocacy training has also helped campaign, as in the case of the RNPM’s and encouraged some members of the efforts to improve sexual and reproductive RNPM to participate in local politics not health services and information for youth. only through advocacy activities, but also by At the central level, government policy running for office. Several members of the promotes services for youth, in practice, RNPM have been elected as municipal 38 PERU council members due in large part because campaigns that have yielded wide-ranging their new political skills helped them results. The results include the formation of negotiate a high placement in the electoral networks of councilwomen devoted to lists. These women are now able to work for gender issues such as sexual and improved services for women from within reproductive health, the incorporation of positions of power in local government. sexual and reproductive health issues into municipal government programs, new programs to address the sexual and Conclusion reproductive health needs of youth, and the creation of citizen oversight committees. Forging an alliance with the RNPM Although decentralization poses many has resulted in the creation of a network of challenges to the effective delivery of skilled civil society advocates throughout services, the RNPM is now in a position to Peru who are capable of generating the maximize decentralization’s potential by commitment of local elected leaders to mobilizing communities to work together to sexual and reproductive health efforts. The address local needs. groups in the network have also gained the technical competence to assess needs in Opportunities for collaboration their communities and to develop proposals between the public and private sectors have for government authorities and local elected increased in part because relations between leaders. Recognizing the constructive role government and civil society representatives that civil society groups are playing, local are more horizontal than at the central level. authorities are beginning to value their As a result, the Ministry of Women and participation and are becoming more Human Development has contracted with receptive to working in collaboration with the RNPM to train its staff on the issue of them. The RNPM has gained considerable violence against women, and the MOH has expertise and has had an opportunity to likewise contracted with the RNPM to raise demonstrate what it can accomplish. At awareness among healthcare providers of both the national and local levels, sexual and reproductive rights. government agencies are recognizing the In conclusion, civil society groups in RNPM for its technical competence. Peru have been able to establish The results achieved by the RNPM mechanisms for true partnership with branches demonstrate the impact of government representatives at the effective civil society participation at the decentralized level and are now working decentralized level. With the support of together to design and implement minigrants, the departmental branches of appropriate policies and programs in sexual the RNPM have carried out several advocacy and reproductive health. 39 CHAPTER 5 Guatemala Case Study Lucia Merino Cindy Cisek Mirna Monteneg Montenegrro Lilian Castañeda 41 Introduction per woman, and contraceptive prevalence is relatively low at 38 percent. The poor The Guatemala case study is unique. reproductive health status of women is Facing particularly strong impediments after complicated by gender inequities that the end of an extremely long and violent pervade almost every aspect of Guatemalan civil war, Guatemala has moved toward society. In addition, reproductive health decentralized and participatory planning by indicators show dramatic differences for means of a gradual, time-consuming indigenous women, indicating that these process. The advances to date underscore women are subject to gender and other the critical importance of partnerships and inequities. As a result, sexual and the participation of civil society in reproductive health issues are closely linked dramatically recasting the nature of to the larger political context of women’s reproductive health policies. and indigenous people’s rights. Guatemala’s recent history includes a nearly 40-year civil war that lasted from Context 1960 to 1996. It is roughly estimated that Guatemala is a multilingual and 180,000 people died during the civil war multicultural country of approximately 11.9 (Russel, 1996), leaving emotional and million people. Mayan indigenous people psychological scars on Guatemala’s peoples represent approximately 60 percent of the and communities. population and Ladino people approximately 39 percent of the population (Ikeda, 2000). The two remaining minor groups, the Participation Garifuna and Xincas, represent less than 1 On December 29, 1996, the percent of the total population. Although Guatemalan government and the the official language is Spanish, 21 different Guatemalan National Revolutionary Unity languages are spoken in Guatemala. Half of signed a formal peace agreement to end the rural women speak only their indigenous civil war—the Agreement on a Firm and languages. Two of every three Guatemalans Lasting Peace (known as the Peace live in rural areas. Approximately 80 Accords). Based largely on the Universal percent of the total population and 93 Declaration for Human Rights,1 the Peace percent of the indigenous population live in Accords set the foundation for a new poverty. The highest levels of illiteracy are relationship between civil society and found among indigenous women in rural government. The accords clearly set the areas, with levels reaching 80 to 90 percent stage for increased participation and in the northwestern parts of the country democratization within Guatemalan society; (GSD Consultants, 1999). in fact, many of the accord’s articles Guatemala is faced with the highest specifically mention women and indigenous maternal mortality rate in the Central women. Among its other provisions, the American region and one of the highest in Peace Accords promised to rectify the all of Latin America—190 mothers die for inequities facing indigenous groups and every 100,000 births (Guatemala DHS, 1998–99). Women give birth at too young an age and also too late in their reproductive life cycles, and many 1 The Universal Declaration for Human Rights was the first pregnancies occur within less than 24 universal document developed addressing human rights; it was months of the last pregnancy. Guatemala’s developed by the United Nations in 1948 and ratified by many countries following World War II. On December 11, 1998, the total fertility rate is estimated at five births document celebrated its 50th anniversary. 42 GUATEMALA women in Guatemalan society and to Secretary of Planning and Programming promote a broader model for economic and (SEGEPLAN) is the government agency social development by involving local responsible for strengthening the leaders and advocating the participation of Development Councils as the planners for women (Ikeda, 2000). For example, the local development. Through executive accords call for decree in 1997, the government refined v guaranteeing women’s right to organize SEGEPLAN’s responsibilities so the agency and participate on an equal basis with would be able to respond more fully to the men in all levels of decision making; needs of the local councils. In addition, the decree strengthened and modernized v guaranteeing equal rights for men and SEGEPLAN to improve the agency’s women, particularly in the agricultural capabilities (Mora, 2000). and household sectors; Decentralization has been v strengthening the active participation of implemented primarily as part of overall local governments, communities, and health sector reform started in 1994 (PAHO, organized groups in planning, 1999). With support from the Interamerican implementing, and executing local Development Bank, the Guatemalan programs and services; government launched an initiative to v guaranteeing women’s right to access to increase the coverage of health care services integrated health care and adequate and to reach populations that had never medical services without discrimination; before received public sector support for and health care. The Integrated Health Services v recognizing the vulnerability and System (SIAS) includes a “minimum” defenselessness of indigenous women package of services as well as the due to double discrimination based on participation of local communities. The the women’s gender and indigenous SIAS decentralized responsibilities and status. resources to the local directorates of the Ministry of Health, thereby increasing the autonomy of these bodies in relation to the Decentralization formulation and implementation of their assigned health budgets and the external Guatemala is organized into 22 contracting of services. Through the SAIS departments and 330 autonomous health care model, Guatemala has gradually municipalities. The past three years have diversified the number and type of health seen several normative advances designed care services. The number of to increase the nation’s democratization and nongovernmental and private organizations decentralization. Enacted in 1987, the Law involved in the SIAS model increased from of Urban and Rural Development Councils 21 in 1997 to an estimated 90 in 1999 (Mora, (Decree 52–87) laid the foundation for a 2000). political, institutional, and legal framework that transferred decision making and Despite the above advances, the financial control to local governments Guatemalan government remains highly through the installation of local centralized in most sectors. The country is Development Councils. The law also gave still in the early stages of decentralization. citizens the legal right to participate actively The previous government administration in local governance activities. It promotes, that lasted from 1996 to 1999 failed to make guarantees, and ensures social participation the political decisions required to of all sectors of Guatemalan society. The institutionalize or accelerate the transfer of power. 43 Sexual and Reproductive particular. Challenges included the lack of a Health Policy tradition of civil society participation, the low status of women, divisiveness, cultural In Guatemala, various legal diversity, lack of advocacy skills, and foundations support women’s reproductive government resistance (Wilson, 2000). The health rights, including the Constitution; civil war that affected Guatemala for more the Law for the Promotion of Dignity for than three decades repressed all forms of Women; Decree 67–97, which called for the organized expression. The population elimination of all forms of discrimination learned to be passive, and women in against women; and the mention in the particular lived in a culture of silence Peace Accords of women’s rights to perpetuated by their low level of income and integrated health (although reproductive educational attainment and the fact that health is not specifically named). Despite a many women do not speak Spanish. The relatively strong legal framework, political protracted war created deep-seated support for reproductive health and family suspicions about democratic processes and planning from the period of 1996 to 1999 the judicial system. In addition to the was weak at best. Beginning in1996, the perceived risks associated with “speaking public sector came under the strong out,” the population demonstrated an influence of an organized opposition overall lack of awareness about how civil movement against reproductive health at a society could take action, what strategies to time when the national reproductive health use, how to mobilize popular support, and and family planning program suffered from a how to influence decision making. Many lack of leadership and orientation and thus people had no knowledge or concept of how was virtually unable to respond. These same the government worked or where the power forces have struggled to control the public resided. Compounding the problem of a debate on issues essential to reproductive lack of a culture of participation was the health, such as human sexuality, further government’s resistance to respond to the impeding the population’s access to demands of civil society. Another major information and education. As a result, challenge was the relatively fragile political government policies and programs relating environment for reproductive health issues, to reproductive health and family planning especially given the controversy and debates services were ambiguous at best and often surrounding sexual and reproductive health nonexistent. In the decentralized SIAS issues. Even among groups that favored health system, pregnancy and delivery women’s rights, some still operated under services were virtually the only aspect of taboos and prejudices related to sexual and reproductive health that received attention reproductive health, including family and resources. Furthermore, the lack of planning. Many of these perceptions were participation of civil society, particularly of related to a lack of accurate information women, in political processes exacerbated about what reproductive health included— the political apathy toward reproductive and rumors linking reproductive health to health and especially family planning abortion and population control. These programs (Duarte, 2000). rumors biased both conservative and liberal groups against reproductive health policies. Challenges In Guatemala, many challenges Interventions and Results impeded effective political participation by Policy-related activities began in 1996 civil society and by women’s groups in with the initiation of activities with NGOs 44 GUATEMALA interested in ensuring the participatory Facilitating the Development implementation of the Peace Accords, and Formation of Networks despite a lack of political support for such and Coalitions from Civil activities. At the time, policy decisions were still highly centralized (with little political Society will to change), and reproductive health and Women’s Network to Build Peace family planning were extremely sensitive Despite Guatemala’s precarious issues. These factors created a challenging political environment, there were important and precarious environment. opportunities to provide support to key Due to the highly centralized NGOs, which facilitated the pooling of environment, work began at the national skills and knowledge and increased financial level in the capital, Guatemala City, and and political leverage. In November 1996, then in other locations as opportunities several women’s organizations solicited presented themselves, gradually moving to support to facilitate and guide the process integrate organizations from various of forming a network. The member departments with their counterparts in the organizations called their new group the capital. More recently, with a changing Women’s Network for Building Peace— political environment, departmental offices defining its mission as the promotion of have also received assistance. Participatory policies and actions to improve women’s activities in Guatemala have focused on the status within a framework of equity, gender following interventions: sensitivity, and democracy. v facilitating the development and Initially, the Women’s Network for formation of networks and coalitions Building Peace included 13 organizations from civil society to support advocacy representing women from academia, women efforts; working as physicians and health care providers, other professionals, and v empowering the networks and other civil indigenous women. Currently, the Women’s society and community organizations to Network represents 28 organizations with participate in the policy formulation over 5,000 members. The network is legally process and to articulate their needs by formed and inscribed in the Public strengthening their technical and Registry—after three years of dealing with advocacy skills; the political bureaucracy. Its structure v encouraging a more participatory process includes a Coordinating Commission of for the identification and analysis of three members that change every two years needs and the definition of priorities in and a General Assembly. The network forms the health sector; and work groups according to operational and v creating opportunities for interaction technical areas and is initiating expansion to between civil society and government (at the departmental level. both the national and departmental levels) during different stages of the The Cairo Action Group planning and policy process. The Cairo Action Group (CAG) was formed in spring 1999 to bring the sexual and reproductive health agenda to the forefront and to advance Guatemala’s official position at the ICPD+5 conference in New York. The CAG is a small network representing only seven organizations 45 (including the Women’s Network, which was Women’s Network to Build Peace: the foundation for formation of the CAG) Strengthening Women’s Participation and other organizations interested in in the Policy Process reproductive health issues outside the Initially, the Women’s Network and its context of the Women’s Network. The CAG’s members were based in Guatemala City, the focus is to promote the acceptance and nation’s capital. They received training implementation of the ICPD Programme of designed to improve members’ advocacy Action. The CAG has generated awareness skills; providing instructions in the use and of the contents of the ICPD Programme of application of information in the decision- Action and promoted the importance of making process; improving negotiating supporting the ICPD initiatives contained skills, strategic planning, and self- therein. management; and increasing knowledge about sexual and reproductive rights, gender equality, and integrated health. The Empowering the Network, Women’s Network subsequently Civil Society, and implemented its own activities, including Community Organizations to the design and implementation of advocacy Participate in the Policy campaigns. The training and technical assistance varied with the network’s Formulation Process members. Although more support was The Women’s Network and NGOs required than originally anticipated, the goal interested in social and economic has been to ensure that the member groups development often found themselves in the Woman’s Network have a solid working with limited technical capabilities foundation to support their advocacy and and a lack of specialization. Because they participatory activities. tended to operate in fear (after so many As a result of its improved skills, the years of political repression) and isolation, Women’s Network has been successful in they frequently duplicated efforts (Duarte, advocating and ensuring a participatory 2000). These counterparts encountered policy development environment; its main resistance from the Guatemalan government objective has been to ensure the (which clearly opposed reproductive health) participation of women in the policy as well as many administrative obstacles to process. For example, the network legally organizing themselves. Gender advocated to ensure that the Law on Urban training combined with participatory and Rural Development Councils—the exchange empowered women’s groups and mechanism that promotes, guarantees, and allowed them to recognize their potential ensures social participation of all sectors of and opportunities. They also needed to be Guatemalan society—explicitly included able to analyze and identify a given issue women’s participation. Unfortunately, the and develop a proposal for action and law, which was part of a package containing change. Increasing their technical various other reforms to the Constitution, knowledge with respect to reproductive was rejected by popular vote in 1998. The health statistics and population and network then changed strategies and lobbied development themes enabled them to for reforms to the local Development develop their own materials and Council as provided in the Law for the presentations. Promotion and Dignity for Women; 46 GUATEMALA ultimately, the reforms passed. With resources from the governor to open its own increasing skills and leverage, the network’s offices. The Sacatepequez Women’s Forum achievements have become increasingly is currently developing an advocacy important. campaign for the installation of maternity In 1999, the Women’s Network played waiting homes in each municipality whereby a critical role in developing the platform for rural women can be attended by capable and women’s integrated health that was trained medical personnel in the several incorporated into the Civil Society Assembly days preceeding delivery. The Sacatepequez (CSA)—of which the network is a Women’s Forum also secured a permanent member—for formal presentation to position on the local Urban and Rural government and presidential candidates. The Development Council. In Escuintla, the To counter the Catholic CSA is the official mechanism created by the network brought together a group of Church’s systematic government for decision making related to professional women and physicians who opposition to sexual and the Peace Accords. have initiated coordination with the reproductive health, the Regional Directorates of the Ministry of With a new administration taking Health and the Guatemalan Social Security Women’s Network office in 2000, the Women’s Network was successfully lobbied for the Institute to increase coverage of ready to respond to a changed political reproductive health services in Escuintla. Church’s recognition of the environment and the administration’s right to information. In Escuintla has an enormous need for commitment to increase the level of reproductive health services because of the January 1998, the participation, to develop the role of the Episcopal Conference of the numbers of migrants who pass through from Development Councils, and to pursue the El Salvador to Mexico and because Catholic Church sent an decentralization process. Recognizing the unprecedented letter to prostitution, sexually transmitted infection, opportunity to influence participatory and HIV are on the rise. Although local Guatemala’s Vice planning and policies through the councils, President stating: activities are just beginning, the network’s the network began working at the ability to recognize these opportunities and “All persons have the right decentralized level. to be informed before act on them clearly represents a major With the benefit of some financial and achievement in promoting participatory making a decision, for such technical support, the Women’s Network decentralization in Guatemala. motive, it should be implemented an advocacy campaign ensured that the people The Women’s Network has come to designed to lobby for fulfillment of both the have access to complete represent the voices of many women. The participation agreement and integrated and accurate information organization has increased women’s health for women as described in the Peace about 100% of the family representation in national and local Accords. The network’s objective was to planning methods in order policymaking and is poised to influence a encourage women to participate in the to have the liberty of newly revitalized decentralization process in decision-making process for women’s choosing a method.” Guatemala. The growth process has been integrated health by networking at both the The network has continued one of diversification—the network now national and local levels. to lobby the Catholic includes representatives from various Church through periodic The advocacy campaign was departments as well as from various visits, policy presentations, implemented in the capital and in the indigenous groups. The process has also and providing scientific departments of Quetzaltenango, Cobán-Alta been one of learning for the network and its information. Recent Verapaz, Escuintla, Huhuetenango, members. It has gradually developed declarations from the Sacatepequez, and Sololá and involved local leadership skills, gained the ability to deal MOH also seem to reflect counterparts, including the National Office with internal conflicts, and learned to put the Church’s new tolerance for Women. In Sacatepequez, the network democratic principles and participatory for reproductive health. helped consolidate the Sacatepequez ideas into practice within the organizations Women’s Forum (affiliated with the network), so that the views of all members are taken which has succeeded in obtaining financial into consideration. 47 CAG: Promoting political dialogue on new opportunities for national and local reproductive health organizations to exercise their citizenship by Assistance to the CAG has included persuading political leaders and recently various workshops as well as a “learn-by- elected officials to pledge their support for women’s participation and women’s In May 1999, the CAG doing” approach designed to improve integrated health issues. brought together and members’ advocacy skills, enhance the use informed a group of 25 and application of information in the NGOs about the Cairo decision-making process, and increase CALDH: Supporting legal advances in platform and the health knowledge about sexual and reproductive reproductive health policy programs in Guatemala rights, gender equality, and integrated Beginning in 1997, the Center for related to maternal, sexual, health. During the ICPD+5 process in 1999, Legal Action in Human Rights (CALDH) and reproductive health, the CAG publicly and for the first time trained 215 indigenous rural women stimulating this group to tackled the topic of sexual and reproductive representing 75 different organizations in negotiate with the health, contributing to the official the conduct of training on sexual rights and government to discuss and recognition of the importance of reproductive health. The organizations in analyze specific proposals reproductive health and family planning in turn identified their own health priorities related to reproductive the final government document presented at and developed local advocacy campaigns in health. The group the ICPD+5 meeting. support of government action. CALDH’s and elaborated a political With some financial and technical its partners’ advocacy campaigns for sexual declaration from civil society support, the CAG implemented a campaign and reproductive rights contributed to the that was published in the to advocate for implementation of the ICPD April 1999 passage of the Law for Advocacy media demanding that the Programme of Action in Guatemala and to and Fundamental Dignity for Women, which government respond to the work toward government and civil society confirmed women’s right to access to real needs of Guatemalan agreement to a set of commitments. The reproductive and family planning services women according to the geographic reach of the campaign was in and affirmed the government’s responsibility strategic orientation of the Guatemala City and the departments of to guarantee access through public health ICPD Programme of Quetzaltenango, Escuintla, Santa Rosa, services. The law also reformed the local Action and that they Sacatepequez, and Chimaltenango—where Development Councils to guarantee the assign appropriate technical the CAG involved NGOs in advocacy presence of women on the councils. This and financial resources to activities with local governments to help law provided specific benefits for establish a Population and accelerate implementation of the ICPD indigenous women in response to a proposal Development policy. Programme of Action. The CAG has that originated with the Kabuk indigenous gradually expanded its activities and realm group. CALDH recognizes passage of the of influence beyond implementation of the law as a first step in improving access to Programme of Action. reproductive health. In Quetzaltenango, the most To ensure that the process continues, important city after the capital, the CAG CALDH recently initiated a campaign of also played a key role in involving local policy reforms and participation in support of NGOs in and promoting policy dialogue reproductive and women’s rights. It has also with congressional candidates on women’s developed a proposal to reform the National and HIV/AIDS issues. More recently, the Health Code that includes the revision of CAG worked extensively during the eight articles to incorporate a gender- elections to increase candidates’ awareness sensitive approach calling for the elimination of reproductive health issues and to place of discrimination against women and the issues on the political agenda. Many encouraging women’s participation. The candidates incorporated terminology from proposal also includes mechanisms to the CAG into their speeches. The change of support reproductive health issues. At the government in early 2000 has opened up same time, CALDH has equipped NGOs, 48 GUATEMALA institutions, interested groups, and individual norms and guides for service delivery, the women with appropriate information to lack of knowledge about the political and support policy and legal actions for the legal context for family planning, and the fulfillment of reproductive and women’s lack of institutionalization of family rights. It conducted 10 departmental-level planning programs. As a result of the survey, workshops that reached representatives of 40 the Ministry of Health issued an advisory different NGOs and developed a legal guide letter to all 22 department heads for women and community organizations that emphasizing the importance of access to includes actions related to sexual and family planning information and services for reproductive rights. CALDH also participates all persons. The MOH has also initiated a as an active member of both the Women’s process to revise its technical norms Network and CAG. regarding family planning and reproductive health services and has initiated a planning process to increase the availability of the Encouraging a More operational guides for family planning Participatory Process for the services. Identification and Analysis of In early 1999, decentralized activities Needs and Definition of began in Quetzaltenango, San Marcos, and Priorities in the Health Sector Cobán by supporting local MOH department heads in using information and Due to the political reticence data in the formulation of their plans and associated with sexual and reproductive programs. Activities also included health issues, it was difficult to provide additional training programs for the direct support to government agencies, departmental health councils and including the Ministry of Health, except for department heads of the MOH. Other much-needed technical assistance in one activities extended to the initiation of a important area—the analysis and use of coordinated plan with the MOH, the population and reproductive health data for Association of Guatemalan Female decision making. Part of the assistance Physicians (AGMM), and the Association of included conducting a survey to assess Gynecology and Obstetrics (AGOG) that medical and institutional barriers to family calls for disseminating information on the planning service delivery. The 1999 survey reproductive health situation and the results included interviews with health care of the medical barriers study, providing an professionals as well as with clients from update on contraceptive technology, and health centers and clinics operated by the distributing information about the political Ministry of Health, the Social Security and legal framework for reproductive health Institute, and APROFAM (the largest NGO and family planning. providing reproductive health services). The survey was conducted in all departments except Petén. Creating Opportunities for The survey provided critical Government and Civil information on the reality of reproductive Society to Interact at the health policy at the service delivery level. It Departmental Level identified 12 different barriers that inhibit access to family planning services. Those In addition to providing assistance at barriers are largely associated with service the departmental level in the Ministry of providers’ biases and lack of knowledge, the Health in Quetzaltenango, San Marcos, and absence or lack of knowledge about the Cobán Alta-Verapaz, work began on 49 reinforcing the technical capabilities of local Secretary of Planning to conduct a workshop community and civil society organizations to for the local Development Council and “…the health situation is enable them to strengthen their advocacy government. The participatory planning not going to improve by skills. Nine workshops reached reached 30 workshop considered the sociodemographic simply increasing the different local organizations and resulted in characteristics of the department, the number of doctors in the the establishment of a collaborative requirements of civil society organizations, Ministry of Health. The relationship with six organizations at the and the interests of the community. direct participation of the departmental level: the Coordinator of During a two-year period, four local population and MAM Organizations (COMAM), the Union women’s organizations in five departments organizations working in of Industry and Commerce Workers designed and implemented advocacy health is important…” (SINTRAICIM), the Foundation of the campaigns. As a result of the campaigns, 13 Northern Mayan Woman (FUNMAYAN), the Quote from Dr. Nestor political and social leaders spoke out in Carrillo, Director from the Association for the Guatemalan favor of integrated health policies for Sololá Area of the MOH, Development Maya (ADEGMAYA), the women. Furthermore, eight additional NGO congratulating OMET for their Association for the Progress of Women community organizations elaborated their initiative, May 2000 (AMVA), and the Organization of Tzutujiles own advocacy plans. Women Stars (OMET). These organizations initiated policy dialogue and advocacy campaigns with department heads in the Conclusion Ministry of Health and local governments in order to improve health services and While most of the outcomes to date in broaden women’s participation in the Guatemala have occurred at the national political and decision-making processes level, interventions are increasingly taking related to family planning and reproductive place at the departmental and municipal health at the departmental level. In Sololá levels, thereby ensuring adequate attention and Quetzaltenango, OMET and AMVA to reproductive health and gender issues succeeded in mobilizing private sector and promoting women’s participation in the resources (local radio and television policy process. The Guatemala experience channels) to support the local Ministry of has demonstrated that a legal and political Health in securing free airtime to deliver framework—as defined in the Peace messages on integrated and reproductive Accords—is insufficient to ensure access to health. reproductive health and family planning “I want to support your The advocacy campaigns have created services unless community and civil society initiatives, but I also need a favorable environment for sexual and organizations engage in advocacy. The your support to implement reproductive health policies at the participatory process initiated at the reforms to the maternal departmental level. In Alta Verapaz, Guatemala’s national and departmental and child health program ADEGMAYA presented a proposal directly levels ensures that advocacy efforts will that is trying to achieve from the MOH to the program director for continue to support the framework integrated health for integrated health that would include and established by the Peace Accords. The women and the prioritize reproductive health norms and incorporation of civil society groups has incorporation of girls and protocols in the SIAS. helped alleviate the central government adolescents.” monopoly on power and processes while An NGO working in Petén, the Quote from Dr. Elsy Camey diversifying the individuals and groups from de Astorga, MOH Program department farthest from the Guatemalan various levels involved in dialogue, Director for Integrated Health capital, also received assistance. The NGO proposals, decision making, for Women, Children, and REMEDIOS solicited help to conduct a implementation, and monitoring. With these Adolescents, during workshop for local organizations on advances, society as a whole is experiencing ADEGMAYA’s proposal population policy and development. Later, presentation, July 2000 an increased awareness of the issues, and these same groups collaborated with Petén’s 50 GUATEMALA the opening of dialogue on reproductive strengths and weaknesses, to trust the health and family planning has itself been a participatory process, and to ask for significant accomplishment. assistance. The new administration is The technical assistance that beginning to draft a document representing counterparts in Guatemala received has laid a population and development plan for the foundation for the groups to continue Guatemala. SEGEPLAN has requested strengthening health sector reform and technical assistance to train the decentralization. In the future, these groups Development Councils’ delegates in will be poised to take advantage of new participatory planning. The Ministry of opportunities for advocacy. The Health is also beginning to develop its own administration in power since early 2000 is reproductive health policies. The result is demonstrating an increased political will to that the conservative mindset and taboos support participation and decentralization that dominated sexual and reproductive activities. The government is addressing the health issues in Guatemala for decades are issue of women’s integrated health and gradually giving way thanks to the work of “The Ministry of Public reproductive health and appears sufficiently groups such as CAG, the Women’s Network, Health and Social broad-minded to recognize its own and CALDH in strengthening participatory Assistance calls for the processes and decentralization. active participation of the population, organizations, and other institutions in the development of strategies for transformation and sustainable development, with the conviction that it will only be in this way that we can create the favorable sociodemographic conditions to reduce inequity and poverty.” Public declaration from the Ministry of Health on July 11, 2000, World Population Day 51 CHAPTER 6 Promoting Successful Participatory Decentralization: Lessons Learned from Policy Activities Mary Kincaid Taly Valenzuela Valenzuela Sandra Alliag Alliagaa Introduction Promoting Participatory As governments in Latin America Decentralization with decentralize their health services, one key a Focus on Sexual and to success is to strengthen local citizens’ Reproductive Health groups so that they can participate in 1. Work at several levels (from national defining the services they need. Whether to local) and across sectors. decentralization is taking place at the state, 2. Be flexible; there is no blueprint for provincial, or municipal level, empowering fostering successful participation in civil society to participate in governance is decentralization. crucial. 3. Approach reproductive health through participatory planning and pay Decentralization, as discussed in attention to process. Chapter 1, is intended to make policies and 4. Maintain a country presence. services more responsive to the needs of the 5. Empower people to ensure democratic Never doubt that a small local population and to make services more decision making in project activities. group of thoughtful, efficient, equitable, and of higher quality 6. Work objectively with a range of committed citizens can than under a centralized system. Yet, groups. change the world; indeed, shifting decision-making power from a 7. Address gender when working on it is the only thing that federal office to a state office does not by sexual and reproductive health. ever has. itself guarantee a better response. The 8. Make use of information and teach others to do so. —Margaret Mead country case studies in chapters 2 through 5 show that broad participation by citizens in 9. Take a short- and long-term decision making can provide the catalyst perspective and follow up. needed to ensure more responsive and 10. Include the media in participatory efficient policies and services. processes. The purpose of Chapter 6 is to distill the lessons learned by the POLICY Project after five years of helping promote 1. Work at several levels and across participatory policy processes at the sectors.. decentralized level in Latin American While it is important to conduct a countries. The lessons are intended to guide country assessment and promote continuing reproductive health policy work partnership at the national level, project and to help others promote partnership and activities need to move quickly to the state participation at the national and and local level if they are to prove effective. decentralized levels in both the LAC region Many LAC countries have found and elsewhere. decentralization difficult in terms of both fully understanding what it is and learning how to implement it. The difficulty with Successful Practices decentralization is mirrored at all levels of administration. Thus, working at the various Chapters 2 through 5 described how levels at which policy is made and “small groups of thoughtful, committed implemented, often extending down to the citizens can change the world” to influence municipal levels, is critical. sexual and reproductive health policy. Based on experiences in Bolivia, Mexico, Peru, and Assistance should be tailored to Guatemala, 10 common practices shaped whether activities are occurring with policy work to facilitate participatory national leaders or local communities. For decentralization (see box). example, policy dialogue and advocacy work frequently involve reducing direct and 54 LATIN AMERICA & THE CARIBBEAN indirect opposition to decentralization, varying degrees in many municipalities. allaying politicians’ and central bureaucrats’ With training in participatory planning professional and personal concerns about methods and workshops on gender and transferring power and responsibility to reproductive health issues, public officials others, and raising awareness about local and community representatives gained a problems that can be better dealt with by deeper appreciation for the laws. Broader actions at the decentralized or local level. In participation resulted in increased local Peru, for example, a national network of support for reproductive health interventions NGOs was able, with assistance, to bring and gender issues. After two years of policymakers and the medical community assistance, the annual development plans together with a group of women’s advocates in six Bolivian municipalities emphasized and rural women. The women recounted reproductive health and/or related gender how the national system of contraceptive issues, with resources allocated for method targets led to violations of sexual corresponding programs. and reproductive rights in local public Creating consensus between the public health clinics. The meeting of policymakers, sector and civil society is the most effective medical professionals, and women was way to improve the policy environment. In all instrumental in spurring a national dialogue case study countries, representatives from on a target-free approach to family planning government and civil society—both at the that would be more responsive to local national and local levels—came together to women’s needs and rights. identify problems and craft mutually At the state and local levels, technical acceptable solutions. In most cases, the assistance and training helped policymakers, solutions were built on interventions that civil society organizations, and individual government and civil society organizations citizens understand civic roles, were already implementing. The solutions not responsibilities, and opportunities while only drew on a broad array of resources, strengthening citizen’s skills for skills, and approaches but also ultimately participating in and influencing local proved sustainable. decision making. In Mexico, state-level strategic planning groups for HIV/AIDS 2. Be flexible. brought together a range of participants from several sectors. By working together, There is no blueprint for fostering the groups gained an understanding about successful participation in decentralization. the decentralization process in the health At the state and local levels, cultural and sector, decentralization’s impact on state geographic differences as well as differences funding for HIV/AIDS programs, and the in power, individual personalities, importance of mobilizing the community infrastructure, and other variables influence and its leaders to participate in policy the extent of participation. Project activities decisions about HIV/AIDS. After week-long take place in richly varied, intense, and workshops and subsequent assistance, the fascinating local settings. Approaches and groups initiated participatory multisectoral schedules must be flexible in the face of strategic planning, built a coordinated uncertain, complex, and unpredictable response to the epidemic, and created circumstances. The chapter on Mexico puts momentum to influence state policies. it succinctly, “A very important part of the process in general has been to find the In Bolivia, two key laws—one on equilibrium between federal policies and the decentralization and the other on citizen states’ independence, demonstrating this participation—had been in place for several respect for the decentralization process years but had been implemented only to while still complying with federal guidance. 55 We intervene, yes, but with a low profile as Even though it may be difficult to facilitators, respectful of the history and measure and report on adequately, the customs in each state. We stimulate local process of participatory planning is a participation at the same time that we valuable result in itself. To capture process demonstrate to the federal authorities the results, qualitative indicators can be used to benefits of local participation in decision assess the degree of participation achieved. making.” For example, a desired result in Peru is to Fostering the policy process requires strengthen collaboration between the constant monitoring of potential governmental and nongovernmental sectors. changes in government and leadership and Indicators might include the number of the development of strategic alternatives to intersectoral groups formed that continue to deal with slow-downs and even dramatic meet on a regular basis and the number of changes in direction. For example, a policies and programs developed with the conservative minister or governor could participation of civil society organizations. replace a liberal one and decree In Bolivia, a desired result is “a planning reproductive health and family planning a process that is participatory.” This indicator taboo subject. is measured by interviewing participants in the planning process both at intervention and comparison sites and asking them a 3. Approach reproductive health series of questions about the frequency, through participatory planning and degree, and nature of their participation. In pay attention to process.. this way, the indicators capture how the Working in a conservative country or policy process was affected in Peru and setting does not necessarily mean that Bolivia rather than just the outcomes of sexual and reproductive health and rights, policy change. gender issues, HIV/AIDS, and other sensitive areas cannot be addressed. In fact, 4. Maintain a country presence. decentralization can facilitate work on these issues. Sexual and reproductive health—by It is difficult to work in participatory itself a potentially controversial issue—can decentralization without maintaining an in- be introduced within a larger, more country presence. Projects themselves must acceptable framework such as participatory decentralize to achieve results. In addition, planning or women’s political participation. to work in participatory decentralization, Stakeholders work most creatively when they project staff must work in secondary cities are challenged to visualize their own needs, and towns rather than remaining in the including sexual and reproductive health capital. The presence of an in-country team services or programs that address violence expedites movement out of the capital city against women. and makes projects more cost-effective. In addition, country programs can be more In Bolivia, government officials easily designed jointly with local counterparts requested help with training in participatory and then managed by a local advisor. At the planning. The training was designed to use same time, assistance from a project manager reproductive health examples for the group- based in the donor country or elsewhere in work exercises. The training workshops the region can reinforce the in-country work. resulted in a number of requests from This country team arrangement can allow municipalities and civil society for technical project staff to share global and regional assistance on reproductive health and gender experience with the local team, capitalizing issues, as participants recognized the need to on the local advisor’s in-depth knowledge of address these matters in local planning. the country, its people, and practices and 56 LATIN AMERICA & THE CARIBBEAN keeping international travel and other costs 7. Address gender. to a minimum. It is impossible to address sexual and reproductive health without dealing with the 5. Empower people to ensure underlying gender issues. Inequity in the democratic decision making. power and resources accorded to men over women have profound implications for Participation projects will be most women’s sexual and reproductive health and successful if activities empower people and for human rights and development. Projects ensure democratic decision making and can also be most successful by helping transparency. For example, advocacy training groups of women and men use a gender lens in Latin America that includes a training-of- when identifying and addressing trainers component gives local leaders the reproductive health needs. In certain parts skills they need to replicate advocacy training of Bolivia where local gender norms throughout their country. When engaging in discourage women’s participation in policy dialogue with national, state, or local decision making, a workshop venue leaders, civil society representatives and local succeeded in bringing together community leaders should be involved in the women and men to discuss gender and discussions, giving them access to reproductive health issues and to encourage policymakers they might not otherwise meet. women to participate in the local planning Even in workshops, democratic decision process. As a result, more women making can occur when the facilitator asks participated in the planning process in the participants to agree to ground rules and towns where the project conducted the to validate the agenda and workshop workshops than in towns where workshops objectives, making changes as appropriate. were not held. Moreover, the women advocated for programs and services that 6. Work objectively with a range of addressed both their reproductive health groups. needs and related gender and human rights To forge participatory policymaking, it issues such as violence against women in is important to work simultaneously with their communities. several groups rather than to align exclusively with one institution or NGO. By 8. Make use of information and teach diversifying partners, projects can be others to do so. perceived as neutral and objective—not part Access to and use of information are of either the public or private sector and vital to participation. When trained in therefore independent of particular goals participatory processes, civil society groups and biases. Project staff can serve as and local government officials understand facilitators, approaching groups that the need for information. Stakeholders traditionally do not work together and benefit from learning where to find existing bringing them together under the auspices data, how to collect or generalize data to of a neutral project. In the Mexico case answer key policy-related questions and how study, the project’s neutrality played a major to apply the information in activities such as role in the success of participation for policy dialogue, advocacy, and decision activities. Because they perceived project making—a pressing local need. In Peru, staff as free from ideological leanings, advocacy workshops have trained church leaders, conservative politicians, participants in using DHS data to extract radical NGOs, and outspoken citizen relevant information for advocacy goals. As activists agreed to discuss together a a result, local women’s groups subsequently common strategy for addressing HIV/AIDS included DHS data in their policy proposals in their communities. 57 to local municipal and departmental 10. Include the media in participatory officials. Similarly, in Guatemala, a national processes. network of women has improved its capacity The media is crucial as a vehicle for to influence policymaking by adopting a advocacy and policy dialogue as well as a strong emphasis on accessing and using key participant in improving the policy data to reinforce their arguments and policy environment for sexual and reproductive proposals to regional and national health. Journalists can be policy champions government officials, and to leaders of the in their own right. In Guerrero, Mexico, a Catholic Church. television reporter and a newspaper reporter who are members of the HIV/AIDS multisectoral planning group have 9. Take a short- and long-term perspective and follow up. dramatically increased coverage of HIV/ AIDS in the state news and are actively Taking a long-term perspective and recruiting other journalists to help raise providing adequate follow-up are crucial to awareness of the epidemic. the success of programs aimed at strengthening participatory processes. In Bolivia, local groups accustomed to advocating for short-term change learned Summary the importance of formulating and These case studies show how a five- implementing a comprehensive advocacy year policy project worked with local strategy. The concept of thorough and counterparts to build partnerships between complete planning for advocacy requires the public sector and civil society groups to think beyond the short term organizations at the local, regional, and allows them to identify a range of goals national levels. Project activities served as a beyond their immediate needs. stimulus for local groups to engage in Projects must balance short-term advocacy and participatory planning at the project deliverables with long-term national and decentralized levels. The sustainable results. Donor-funded projects results presented for Bolivia, Mexico, Peru, must deliver on results and products on an and Guatemala, speak for themselves: Local annual or biannual basis, thereby organizations are working together with demonstrating project impact. Nevertheless, public officials to increase attention to to ensure sustainability, projects also need to sexual and reproductive health and related focus on achieving long-term results that gender issues in local planning processes improve the policy environment for and policies and to increase funding for reproductive health. In Peru, for example, these programs. 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