Civil society demand for accountability to achieve the 90-90-90 targets: lessons from Eastern and Southern Africa

Power, data and social accountability: defining a community-led monitoring model for strengthened health service delivery

INTRODUCTION

Despite international commitment to achieving the end of HIV as a public health threat, progress is off-track and existing gaps have been exacerbated by COVID-19's collision with existing pandemics. Born out of models of political accountability and historical healthcare advocacy led by people living with HIV, community-led monitoring (CLM) of health service delivery holds potential as a social accountability model to increase the accessibility and quality of health systems. However, the effectiveness of the CLM model in strengthening accountability and improving service delivery relies on its alignment with evidence-based principles for social accountability mechanisms. We propose a set of unifying principles for CLM to support the impact on the quality and availability of health services.

DISCUSSION

Building on the social accountability literature, core CLM implementation principles are defined. CLM programmes include a community-led and independent data collection effort, in which the data tools and methodology are designed by service users and communities most vulnerable to, and most impacted by, service quality. Data are collected routinely, with an emphasis on prioritizing and protecting respondents, and are then be used to conduct routine and community-led advocacy, with the aim of increasing duty-bearer accountability to service users. CLM efforts should represent a broad and collective community response, led independently by impacted communities, incorporating both data collection and advocacy, and should be understood as a long-term approach to building meaningful engagement in systems-wide improvements rather than discrete interventions.

CONCLUSIONS

The CLM model is an important social accountability mechanism for improving the responsiveness of critical health services and systems to communities. By establishing a collective understanding of CLM principles, this model paves the way for improved proliferation of CLM with fidelity of implementation approaches to core principles, rigorous examinations of CLM implementation approaches, impact assessments and evaluations of CLM's influence on service quality improvement.

Advocacy counterstrategies to tobacco industry interference in policymaking: a scoping review of peer-reviewed literature

BACKGROUND

There has been remarkable tobacco control progress in many places around the globe. Tobacco industry interference (TII) has been identified as the most significant barrier to further implementation of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC). Civil society has been recognised as a key actor in countering TII. While TII has been extensively studied for several decades now, there is little research that focuses on counteractions to limit it and their effectiveness to do so. This scoping review seeks to map the peer-reviewed literature on civil society's activities of countering TII in policymaking to identify common counterstrategies and assess their effectiveness.

METHODS

Data sources: We searched Embase, IBSS, JSTOR, PubMed, Science Direct, Scopus and Web of Science using the following terms: ("Tobacco industry" OR "Tobacco compan*") AND. ("corporate political activity" OR "CPA" OR "lobbying" OR "interference") AND ("advoca*" OR "counter*" OR "activi*"), without time or language restrictions.

STUDY SELECTION

Our selection criteria included peer-reviewed studies that were written in English, German, or Spanish that drew on primary data and/or legal and policy documents and reported at least one specific example of civil society members or organisations countering tobacco industry action-based strategies.

DATA EXTRACTION

Advocates' counterstrategies were analysed inductively and countered industry strategies were analysed using the Policy Dystopia Model (PDM). Perceptions of effectiveness of countering attempts were analysed descriptively.

RESULTS

We found five common counterstrategies among 30 included papers covering five WHO regions; 1. Exposing industry conduct and false claims; 2. Accessing decision-makers; 3. Generating and using evidence; 4. Filing a complaint or taking legal action; 5. Mobilising coalition and potential supporters. These counterstrategies were used to work against a wide range of industry strategies, which are captured by five action-based strategies described in the PDM (Coalition Management, Information Management, Direct Access and Influence, Litigation, Reputation Management). While some studies reported the outcome of the countering activities, their impact remained largely underexplored.

CONCLUSION

The review shows that peer-reviewed literature documenting how civil society actors counter TII is scarce. It suggests that advocates employ a range of strategies to counter TII in its different forms and use them flexibly. More work is needed to better understand the effects of their actions. This could stimulate discussions about, and facilitate learning from, past experiences and help to further enhance advocates' capacity.

Current allocations and target apportionment for HIV testing and treatment services for marginalized populations: characterizing PEPFAR investment and strategy

INTRODUCTION

The United States President's Emergency Plan for AIDS Relief (PEPFAR) is a large bilateral funder of the global HIV response whose policy decisions on key populations (KPs) programming determine the shape of the key populations' response in many countries. Understanding the size and relative share of PEPFAR funds going to KPs and the connection between PEPFAR's targets and resulting programming is crucial for successfully serving key populations.

METHODS

Publicly available PEPFAR budgets for key populations' services were assessed by country and geographical region for all 52 countries with budget data in fiscal year (FY) 2020. For the 23 countries which completed a full planning process in FY 2018 and 2019, PEPFAR targets for HIV testing and treatment initiation for key populations were assessed. Expenditures for KP programming were calculated to determine whether shifts in targets translated into programming. Implementing partners were characterized by the level of specialization using the share of assigned targets made up by KPs. The average target per year and implementing partner was calculated for each KP group and indicator.

RESULTS

PEPFAR country KP budgets ranged from US$35,000 to $15.2 million, and the proportion of funding to key populations varied by region, with Eastern and Southern African countries having the lowest proportion. Between FY 2018 and 2019, the KP targets for HIV testing and treatment among KPs increased, whereas expenditures on key populations decreased from US$115.4 to $111.0 million. Of the 11 countries with an increase in HIV testing targets, seven had a decrease in KP expenditures. Of the nine countries with an increase in treatment initiation targets, five had a decrease in KP expenditures. The proportion of targets assigned to partners which do not specialize in key populations increased from FY 2018 to 2019.

CONCLUSIONS

Current key population policies have not resulted in a tight connection between targets and expenditures. This includes assigning a large proportion of key populations programming to partners who do not specialize in key populations, which may weaken the performance management role of the targets. These results signal that a new approach to key populations programming is needed.

Understanding and comparing HIV-related law and policy environments: cross-national data and accountability for the global AIDS response

Law and policy differences help explain why, as HIV-related science has advanced swiftly, some countries have realised remarkable progress on AIDS while others see expanding epidemics. We describe the structure and findings of a new dataset and research platform, the HIV Policy Lab, which fills an important knowledge gap by measuring the HIV-related policy environment across 33 indicators and 194 countries over time, with online access and visualisation. Cross-national indicators can be critical tools in international governance—building social power to monitor state behaviour with the potential to change policy and improve domestic accountability. This new and evolving effort collects data about policy through review of legal documents, official government reports and systematic review of secondary sources. Alignment between national policy environments and global norms is demonstrated through comparison with international public health guidance and agreements. We demonstrate substantial variation in the content of law and policies between countries, regions and policy areas. Given progress in basic and implementation science, it would be tempting to believe most countries have adopted policies aligned with global norms, with a few outliers. Data show this is not the case. Globally, alignment is higher on clinical and treatment policies than on prevention, testing and structural policies. Policy-makers, researchers, civil society, finance agencies and others can use these data to better understand the policy environment within and across countries and support reform. Longitudinal analysis enables evaluation of the impact of laws and policies on HIV outcomes and research about the political drivers of policy choice.