The Evolving Role of UCOP+ Observatory in Healthcare Monitoring and Advocacy in the Democratic Republic of the Congo

1. You have evaluated the results of the UCOP+ Observatory. What are your main conclusions?

Firstly,?L’ Union Congolaise des Organisations des PvVIH?(UCOP+) in the Democratic Republic of the Congo (DRC) has positioned itself as an influential partner of the Ministry of Health (MOH) and of the programs, participating in discussions through providing supporting data, not just guesses or one-off viewpoints. Civil society has its own data production mechanism; and the data collected and analyzed are used to judge the effectiveness of MOH technicians. This strengthens the technical position and influence of civil society.

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Secondly, the Observatory has solved problems linked to access to treatment, sounding the alarm and finding solutions before patients are too badly affected. But, despite its technical expertise and resources, UCOP+ has had little impact on structural problems such as the underfunding of the healthcare system, poor organization of services and problems of governance. In the DRC, antiretroviral drugs (ARVs) and HIV services are theoretically free of charge, but, in practice, most health centres are private, and practice cost recovery. UCOP+ has no control over this problem as the Government does not subsidize health facilities, which is a structural deficit that is complicated to manage. We therefore need to strengthen the political aspect by combining the efforts of other civil society players to create a balance of power that will push the Government to invest more in healthcare. The Observatory shouldn’t be just an “office” that collects data and conducts analyses; as well as its technical function, it should actively encourage improvements in healthcare.

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1. What lessons can you draw from your broad vision of the different types of community monitoring mechanisms, and from the hindsight of over 10 years?

Over the years, we have seen a proliferation of Community-Led Monitoring systems, but, overall, of the approaches used, I observe two main trends:

• The ‘”collaborative’” approach?whereby Observatories cooperate with the MOH authorities in data collection and analysis, and in sharing this to report validation. They have agreements with health services, they interview providers and they validate data with the MOH.
• The “defiant” and conflict approach, in which the Observatory plays a surveillance role; their data collectors are not known to the MOH, they conduct investigations and research and produce data and analysis that the Observatories do not share with the authorities in its draft form. The authorities only find out about the data when the reports are made public.

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When I carry out technical assistance missions on this subject, I recommend the collaborative approach for several reasons:

• Democracy is not sufficiently developed in our countries, in the sense of taking citizens’ views into account in decision-making; so, pressure on the authorities doesn’t always work.
• Citizens don’t have the means to challenge the authorities and get things done. Demonstrations and newspaper articles don’t produce results and the authorities refuse to cooperate.

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That is why the collaborative approach is risky: we must always think of the interests of patients but sometimes certain systems put too much emphasis on collaboration to gain access to data and funding from donors.

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Initially, we didn’t follow any particular model, adapting our approach and tools as situations arose. Then the donor partners took an interest in the Observatories and gave us the means to conduct our activities but this created rigidity. Our responsiveness and adaptability were hampered, as was our autonomy, because the partners have a precise vision and expectations, with their own tools and performance frameworks. We are in danger of losing our community-based, activist character, given the risk of losing funding if cooperation with the Ministry is poor. Expertise France funding was flexible, with direct dialogue with the donor, but with the Global Fund the approach is complex, as support for the Observatory is included in the grant, with bureaucratic management systems.

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1. The RAME (Network?for Access to Essential Medicines)?Observatory?was evaluated this year. How would you sum up your 15 years of experience in Burkina Faso, Guinea and Niger?

Our Observatory was recently evaluated and, overall, the assessment showed that it was relevant and useful in resolving certain dysfunctions. It highlighted an insufficient level of influence, and weak management and coordination capacities for the three national programs. But it also emphasized that we had made considerable progress as a result of our advocacy: today, a measure of our success is that there is a line in the national budget for the purchase of HIV treatment. We were at the heart of the debate on free treatment, we contributed to equipping centres and to resolving numerous stock-outs. In the three countries, stock-outs are less frequent, even if we have no structural influence on the system. The three Observatories continue to operate even after Expertise France funding ceased, and we have mobilized other resources, such as Global Fund grants. The Observatories are recognized and respected, which is a major source of satisfaction.