By guest blogger Beth E. Rivin, M.D., M.P.H.

Holding governments accountable for their legal and political obligations to women’s rights, including the right to the highest attainable standard of health, requires civil society to engage in activities not only at the national level but also at the municipal level of government.  Civil society organizations can assure that governments are complying with their obligations. Measuring and monitoring all aspects of the right to health, including access, are central to this work.  Assessing physical accessibility, economic accessibility (affordability), information accessibility and nondiscrimination, the four dimensions of access to health, can lead to evidence-based advocacy efforts that not only fulfill core human right obligations of accountability, but strengthen health systems and ultimately improve women’s health.1

This is happening in Indonesia.  Uplift International, a Seattle-based NGO working in Indonesia since 1998, is affiliated with the University of Washington School of Law and with the author in her role as Vice President of Programs. The organization is supporting a network of six Indonesian CSOs to conduct activities with the aim of holding local district governments accountable for women’s right to health.  Indonesia became a democracy in 1998 and began to devolve power and authority from the central government to the provincial and district levels of government in 2001.  This Southeast Asian nation has international and domestic legal obligations for women’s right to health.  It ratified CEDAW in 1984, is a State Party to the International Covenant on Economic, Social and Cultural Rights and has a constitution that guarantees many aspects of the right to health.2

Over the last five years, Uplift International and the Indonesian CSO network from Java and Sumatra have conducted a human rights analysis of women’s health policy using the tool, “Health Rights of Women’s Assessment Instrument” or HeRWAI.3,4 It was developed by the former Dutch NGOs, Humanist Committee on Human Rights (HOM) and Aim for human rights, with subsequent field-testing and practical applications by CSOs in many countries, including the Netherlands, Nepal, Bangladesh, Pakistan, Ecuador, South Africa and Kenya.

Responding to community needs, the Indonesian CSO network focused their policy analysis on the issues of access to maternal health and family planning services at the district level for poor and unmarried women. Since health services related to violence against women were also important for the CSO district-level constituencies, there was a complimentary focus on access to services for women and girl victims of violence. The policy analysis led to recommendations for action, which in turn led to evidence-based advocacy training to improve skills among the CSO network members. The CSOs put the training to good use, some working in collaboration with local government to change policy in favor of women’s access and some working directly with communities to facilitate dialogue with the government in expectation that this will lead to policy change. The advocacy efforts were persuasive, grounded in human rights arguments and are continuing to result in positive change. For example, in one district, a new policy was implemented in support of more ambulances for women who were pregnant and needed emergency transportation. The local government officials have also begun a community savings plan scheme for poor women who need maternal health services.  In another district, advocacy efforts have been successful in creating new regulations about the care and protection of women and children victims of violence. The Indonesian CSO network is committed to a long-term advocacy plan with ongoing monitoring of outcomes. Our strategy is to document the experience over time.

Changing policy to improve women’s access to health services requires sustained, multi-pronged efforts.  Engaging the media has been a small, but important component of the program. Print, radio and TV media have been invited to national events, during which results of the health policy analysis were disseminated to representatives from government, academia, international organizations and CSOs. Reporting has not only highlighted the issue of access to maternal health, family planning and violence against women services as a human rights issue, but has drawn attention to the Indonesian CSO network policy recommendations.

Through the advocacy efforts at the district level, the CSOs became increasingly aware that local government officials were claiming there was a link between health service access and lack of funding. As a group, it was decided that the CSO network should investigate the funding of women’s health services through budget analysis. Since health services are administered at the district level, it is was here that the CSOs in our network began the process of analyzing budgets in terms of funding and spending with a health-focused, gender perspective. Several local officials were particularly interested in the gender approach, since there was a new government requirement for gender budget statements. They were keen on obtaining technical assistance from the CSOs to comply with the regulation.

Indonesia has another regulation that is particularly important for accountability of women’s access to health services. There is a national regulation specifically mandating that 10% of the local budgets in the districts must be spent on health services.5 When governments have laws or regulations about minimum health service spending at the local level, accountability is made easier because there is a clear standard. Budget transparency is necessary to assess local government compliance with the 10% budget regulation and to understand the reason behind lack of service access. Investigating government budgets is not always a welcome activity. Although the network CSOs had some difficulties in accessing budgets in a couple of districts, transparency was not an issue in most. The analysis revealed two of the six districts were not in compliance with the 10% health service spending regulation. Overall, disaggregated budgets based on service type were not available, so the exact level of funding for maternal health services, for example, was difficult to ascertain.

The CSO network advocated for reallocation of existing funds to increase funding for health services, which was in line with the prevailing budget strategy of FITRA, Indonesia’s nationally prominent CSO that focuses its work on transparency and budget accountability. The analysis of budget funding revealed excess funding in some budget categories that could be used for needed health services, including those for maternal health, family planning and victims of violence. For example, some municipal budgets included excessive funding for computer equipment not related to health service delivery. The CSOs continue to argue for a reallocation of precious resources to budget for health services that respond to the pressing needs of community women. Local municipalities have asked the CSOs to participate in discussions for the next budget cycle, which is a good sign, but only a first step. The full process of a health-focused, gender budget analysis, as we call it, requires significant time and effort and the CSO network is only at the initial stages of the complete analysis.

It is at the local municipal level of government where one might say “the rubber meets the road.” If health is administered at this level, which is the case in Indonesia, CSO investigations can reveal problems ultimately leading to solutions that will improve health service access for women in the district, with the potential to influence other districts. Focusing on municipal government accountability is a bottom-up approach that appears to offer significant and perhaps sustainable benefits for local constituencies, in this case women.

The Indonesian initiative demonstrates the feasibility of investigating and reporting about women’s health service access and funding in municipalities in order to hold governments accountable for their legal and political commitments to women’s health. The Framework Convention on Global Health has the opportunity to support women’s right to health by articulating the need for accountability at both national and municipal levels of government.  It can do this by first imposing specific obligations on states to immediately collect and disseminate data about maternal health and family planning services at the lowest jurisdictional levels of government. It may also recommend data collection and reporting on health services for victims of violence. There should be a minimum requirement to collect and disseminate age, socio-economic status and sex-disaggregated health service data in relation to service type. Second, the FCGH should call for budget transparency at all levels of government and impose an immediate obligation on states to collect health service funding and spending data at the lowest jurisdictional level of government.  Borrowing on the Indonesia case of a required minimum level of health spending by local governments, the FCGH might recommend that countries consider, or commit them to a process to consider, whether they should similarly institute minimum health spending requirements at the municipal level. Third, the FCGH should recognize the critical role that CSOs play in monitoring accountability for health.  It should call for the international community to participate in immediately supporting CSOs in low and middle income countries to monitor accountability arising from core human rights obligations. The support should be specified as financial and technical, including local CSO training and mentoring. The FCGH should encourage South-South collaboration and broad networking regionally and globally to share best practices and lessons learned in holding all levels of government accountable for their obligations to fulfilling women’s right to health.

References

1.  Committee on Economic, Social and Cultural Rights, General Comment No. 14, The Right to the Highest Attainable Standard of Health, UN Doc. No. E/C.12/2000/4 (2000). Available at http://www.unhchr.ch/tbs/doc.nsf/0/40d009901358b0e2c1256915005090be?Opendocument.

2. “Udang-Udang Dasar Negara Republik Indonesia Tahun 1945, Pasal 28 H (1): Setiap orang berhak hidup sejahtera lahir dan batin, bertempat tinggal, dan mendapatkan lingkungan hidup yang baik dan sehat serta berhak memperoleh pelayanan kesehatan.” Second Amendment to the 1945 Constitution of the Republic of Indonesia (2000), 28 H (1) states that every person is entitled to have a prosperous life, both mentally and physically; have housing and enjoy a good and healthy living environment as well as have the right to obtain health services. Translation by Geni Achnas. Jakarta, Indonesia (2005).

3. LBH Apik, WCC, PKBI,, Rifka Annisa, Mitra Perempuan and Pattiro.

4. Health Rights of Women Assessment Instrument (HeRWAI). Available at http://www.humanrightsimpact.org/themes/womens-human-rights/herwai.

5. Undang-Undang Republik Indonesia Nomor 36 Tahun 2009 Tentang Kesehatan,” Republic of Indonesia Health Law 36/2009.


Beth E. Rivin, M.D., M.P.H. is Vice President of Programs at Uplift International.  She is also Director of the Global Health and Justice Project and Research Associate Professor of Law in the University of Washington School of Law.  She is Adjunct Research Associate Professor of Global Health and Adjunct Research Associate Professor of Bioethics and Humanities in the Schools of Medicine and Public Health at the University of Washington, Seattle, Washington, USA. Additionally, she is Visiting Professor at the Center for Bioethics and Medical Humanities in the Gadjah Mada University Faculty of Medicine, Jogjakarta, Indonesia.