Decentralisation and the provision of health care facilities and services



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Graduate School of Development Studies


Decentralisation and the provision of health care facilities and services: The role of social awareness and mobilisation in promoting the right to health for rural Malawian women



A Research Paper presented by:



Jacob Jacques Nkambule

(MALAWI)


in partial fulfilment of the requirements for obtaining the degree of

MASTERS OF ARTS IN DEVELOPMENT STUDIES

Specialization:

[Human Rights, Development and Social Justice]
(HDS)

Members of the examining committee:

Dr Rachel Kurian [Supervisor]

Dr Jeff Handmaker [Reader]

The Hague, The Netherlands
December, 2009

Disclaimer

This document represents part of the author’s study programme while at the Institute of Social Studies. The views stated therein are those of the author and not necessarily those of the Institute.

Research papers are not made available for circulation outside of the Institute.

Enquiries

Postal address: Institute of Social Studies


P.O. Box 29776
2502 LT The Hague
The Netherlands

Location: Kortenaerkade 12


2518 AX The Hague
The Netherlands

Telephone: +31 70 426 0460

Fax: +31 70 426 0799

Acknowledgements

If it were not for peer pressure, I might not have pursued this MA programme. I got inspiration from three peers (names withheld), most often over a drink. I salute them.

I am equally grateful to my wife, Vida Khumbolawo Nkambule, for taking the responsibility of running the family alone amidst problems like attempted and actual house break-ins. You provided me with strength and determination when my spirits were low.

I am also indebted to the World Council of Churches for funding my studies. In the same vein, appreciation is due to my employer, the Church and Society Programme of the Church of Central Africa Presbyterian (CCAP) of Livingstonia Synod, for their role in securing the sponsorship.

Finally, I acknowledge the immeasurable input and guidance of my two supervisors, Rachel Kurian and Jeff Handmaker, during the design, development and finalisation of this paper. This does not mean in any way that I demean the contribution of other members of staff of ISS. The Convenor for the HDS programme, Karin Arts, deserves special mention for her moral and administrative support whenever called upon.

Table of Contents

Acknowledgements..............................................................................................iii

List of Acronyms..................................................................................................v

Abstract................................................................................................................vii

Relevance to Development Studies......................................................................viii
Chapter 1 Decentralisation and healthcare rights: Context and Concerns..10

1.1 Introduction: Key Facts about Malawi....................................................10

1.2 Decentralisation: a fairly tale or solution?...............................................11

1.3 Decentralisation reforms in Malawi.........................................................12

1.4 Health sector reforms and the right to health...........................................14

1.5 Objectives of the study............................................................................15

1.6 Research questions...................................................................................15

1.7 Justification for the study........................................................................16

1.8 Methodology............................................................................................17

1.9 Limitations...............................................................................................19



Chapter 2 Conceptual Basis and analytical Framework................................20

2.1 Decentralisation, human development and human rights........................20

2.2 Civil society and social awareness on human rights................................21

2.3 Rights-based Approaches........................................................................24

2.4 Analytical Framework: The PANEL......................................................24

2.4.1 Participation.....................................................................................25

2.4.2 Accountability.................................................................................25

2.4.3 Non discrimination..........................................................................25

2.4.4 Empowerment.................................................................................26

2.4.5 Linkage to human rights.................................................................26

2.5 PANEL and the health sector.................................................................26

2.5.1 Availability.....................................................................................27

2.5.2 Accessibility...................................................................................28

2.5.3 Quality...........................................................................................28.

2.6 Conclusion.............................................................................................28
Chapter 3 Role of civil society: Malawi Health Equity Network ................29

3.1 Civil society during the Banda regime (1964 – 1994)...........................29

3.2 Civil society after 1994..........................................................................30

3.3 Reflection on the advocacy work of MHEN..........................................31

3.3.1 Research, documentation and publicity..........................................31

3.3.2 Service Delivery Satisfactions Surveys..........................................32

3.3.3 Access to Essential Medicines Campaign......................................33

3.3.4 Press Releases.................................................................................33

3.4 Public education and mobilisation..........................................................34

3.4.1 Capacity building in community-based research and monitoring..34

3.4.2 Round table discussions..................................................................35

3.4.3 Orientation workshop for media practitioners................................35

3.4.4 National conferences.......................................................................36

3.4.5 Commemoration marches...............................................................38

3.4.6 Alliance building and networking.................................................39

3.4.7 Monitoring and evaluation: Review meetings...............................40

3.5 Conclusion.............................................................................................40
Chapter 4 Research findings and Analysis.............................................41

4.1 Main Findings.......................................................................................41

4.1.1 Knowledge on human rights and the right to health in particular.41

4.1.2 Level of advocacy in promoting the right to health......................45

4.2.3 Level of fulfilment of the right to health.......................................47

4.2 Conclusion.............................................................................................54


Chapter 5 Conclusions and Recommendations......................................55

5.1 Main Conclusions..................................................................................55

5.1.1 Creation of spaces and women participation.................................55

5.1.2 Delivery of social services and expansion of capabilities.............56

5.1.3 The obligation to fulfil the right to health.....................................57

5.2 Recommendations.................................................................................57

5.2.1 Malawi government......................................................................58

5.2.2 Donors...........................................................................................59

5.2.3 Civil society organisations............................................................60

5.2.4 VDCs and ADCs..........................................................................61


Tables

1: Donor commitments under the EHP in US $million.........................46

2: Levels of brain drain (Malawian nurses validated abroad)...............51

3: Vacancy rates in the Ministry of Health...........................................52


Figures

1: Map of Malawi and neighbouring countries.....................................63

2: Map of Malawi showing Mzimba district........................................64
Appendices...............................................................................................65

1: Membership of Elunyeni VDC........................................................65

2: Membership of Mtwalo ADC..........................................................66

3: Question guide for focus group discussions.....................................67



References................................................................................................68

List of Acronyms

ACHPR African Charter for Human and Peoples’ Rights

ADC Area Development Committee

ARV Anti retroviral virus

CBE Community Based Educator

CBO Community Based Organisation

CCAP Church of Central Africa Presbyterian

CEDAW Convention on the Elimination of Discrimination Against all forms of Discrimination

CHRR Centre for Human Rights and Rehabilitation

CSO Civil Society Organisation

DA District Assembly

DC District Commissioner

DfID Department for International Development

DHO District Health Officer

ECOSOC Economic Social Council

EHP Essential Health Package

GoM Government of Malawi

GVH Group Village Headman

HDI Human Development Index

HIV Human Immunodeficiency Virus

HSA Health Surveillance Assistant

ICESCR International Covenant for Economic, Social and Cultural Rights

IEC Information, Communication and Education

IMF International Monetary Fund

MASAF Malawi Social Action Fund

MCP Malawi Congress Party

MDG Millennium Development Goals

MDHS Malawi Demographic and Health Survey

MEC Malawi Electoral Commission

MEJN Malawi Economic Justice Network

MGPDD Malawi-German Program on Democracy and Decentralisation

MHEN Malawi Health Equity Network

MHRC Malawi Human Rights Commission

MP Member of Parliament

NAC National AIDS Commission

NGO Non Governmental Organisation

NORAD Norwegian Agency for International Development

OHCHR Office of the United Nations High Commissioner for Human Rights

PAC Public Affairs Committee

PANEL Participation, Empowerment, Non discrimination, Empowerment and Linkage to human rights

PHC Population and Housing Census

RBA Rights-Based Approaches

SWAp Sector Wide Approach

TA Traditional Authority

UDF United Democratic Front

UDHR Universal Declaration on Human and Peoples Rights

UNDP United Nations Development Programme

UNESCO United Nations Education and Scientific Organisation

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

VDC Village Development Committee

WHO World Health Organisation




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