In their advocacy work, civil society engage government stakeholders who hold significant political power. This requires an in-depth understanding of their political interests and governance structures to identify those who have the power to effect lasting change. In this blog, Lucia Laboso, E4A-MamaYe Country Lead in Kenya shares the experience of civil society engaging political actors in their advocacy.
TRANSFER OF HEALTH STEWARDSHIP FUNCTIONS TO CENTRAL GOVERNMENT
At the stroke of a pen, in what came as a surprise to many because the public had not been aware, the Nairobi City County Governor transferred four key functions to the national government in Kenya. County health service was one of these functions alongside transport services, public works, utilities and ancillary services as well as planning and development. These are huge policy and service delivery functions. In other words, what happened is that Kenya’s wealthiest county had ceded its anchor resource sectors back to the central government.
Whilst the motivation for this action remains unknown, many have speculated that the national government wanted to ensure that the capital city’s infrastructure and services were worthy of its stature. Universal health coverage (UHC) is one of the national government’s big four agenda items. Controlling key functions in Nairobi City County could provide it with the space to directly implement its UHC policy agenda.
The national government thereafter established the Nairobi Metropolitan Services (NMS) directorate, which sits under the President’s office and is led by a military general. This decision brought the county’s civil society organisations (CSOs) back to the drawing board to reflect on the implications of new governance structure on its advocacy plans. The power shift brought about by the centralisation of government functions led to a significant change in the structure and operations of the Nairobi City County Government with new decision makers and interests.
This change happened just before the COVID-19 outbreak, which significantly affected the availability and utilisation of maternal and new-born health (MNH) services. The NMS thereafter closed health facilities providing essential care to mothers and babies due to a surge in COVID-19 infections among healthcare workers, which led to a lack of availability and utilisation of MNH services among women and girls.
CSOs started to gather evidence on the impact of COVID-19 containment measures and the closure of health facilities on access to health and especially MNH services. They then worked with local media to highlight the issues mothers were facing as a result of missing antenatal care visits, forcing some forced to deliver at home in fear of being caught on their way to health facilities during curfew hours. Among other issues, they also drew attention to the reduction in people seeking family planning or immunisation against diseases. But without political action this was not enough.
USING A POLITICAL ECONOMY ANALYSIS APPROACH TO ADVOCACY
The E4A-MamaYe project supports coalitions to undertake advocacy activities that respond to their unique social-political environment. An approach that helps coalitions to do this is political economy analysis (PEA), which looks at how power and resources are distributed and contested.
To achieve the key targets of sustainable development goal 3, ‘health for all’, governments must increase their domestic investment in health and prioritise quality health care. But health care always competes with other governments priorities for limited resources, and the decision on who gets what is often political.
E4A-MamaYe builds the capacity of coalitions use a PEA advocacy approach to help them engage with the right political processes and actors at the right time to achieve improved health outcomes for girls, women and their babies.
A 6-STEP POLITICAL ECONOMY ANALYSIS APPROACH
The PEA revealed a transfer of decision-making power to the national government-controlled NMS, had significant impact on maternal health services. Resources from the national and county government coffers were almost entirely directed to the COVID response, leading to reduced funding for other health issues including MNH.
As the political landscape in Nairobi City County had changed, the maternal and new-born health advocacy coalition had to do things differently to address this problem. This involved establishing new relationships with government and adapting its advocacy to engage with the Nairobi Metropolitan Services.
To better understand the NMS’ role as well as its relationship with the existing department of health services, Nairobi-based CSOs presented a letter requesting an audience with the county assembly committee on health to the clerk of the Nairobi County assembly. The assembly consists of elected leaders that have a constitutional mandate to oversee the Nairobi City County and now Nairobi Metropolitan Services. This clerk granted the CSO’s request by offering to host a special face-to-face meeting between civil society organisations and the elected leaders.
Granting this meeting at a time that the operations of the county assembly had been suspended to curb spread of the COVID-19 pandemic demonstrated a clear and outright commitment to work together with civil society to provide quality health care to the people of Nairobi.
THINKING AND WORKING POLITICALLY
During the meeting, the civil society coalition presented stories of what women and girls have endured due to disruption of critical MNH care after the NMS closed health facilities during the pandemic. Most importantly, they asked the assembly’s elected leaders to engage with the NMS and to share with citizens how the budget development process would work after changes in structure of NMS and the COVID-19 pandemic. This would promote accountability as it ensures that Nairobi residents know who, where and when to engage during the budget making process. Because even with the changes that came with the transfer of functions, constitutional oversight of the NMS remained a responsibility of the elected leaders in Nairobi.
WHAT NEXT FOR NAIROBI CITY COUNTY?
The NMS has not taken any direct actions to address the impact of COVID-19 on MNH services in response to the issues raised by grassroot CSOs. However, it has made important changes to the way in which civil society is engaged, which is an important basis for further action. This includes steps that the NMS has taken to involve civil society organisations in making budget processes more transparent through a joint sitting with the county assembly budget committee.
Using PEA approaches, CSOs are able to identify powerful political allies for the 2021/2022 county budget process and how to target them through their advocacy efforts. In addition, increased budget literacy means that coalitions can continuously monitor how much the Nairobi City County would allocate for health in the new budget in the NMS era. Fourthly, thanks to their greater involvement in the budget process, health advocates now have useful powerful political connections as they champion for improved maternal and new-born health in the county.
In working politically, the place and power of evidence cannot be overemphasised. By enabling coalitions to identify relevant and credible evidence that brings about understanding of key health issues, to package and communicate it in the right way, at the right time and to the right people, data can win the hearts and minds of even the greatest opposition, and thus build support for their causes.
In dynamic and ever-changing environments, PEAs are an ongoing exercise that should be undertaken continuously to effectively adapt advocacy objectives, messages and activities, and to ensure that coalitions are nimble to respond to changing political and power structures.