In partnership with the Center for Reproductive Rights (CRR), CARE Uganda has been responding to the sexual and reproductive health (SRH) crisis in the Pagirinya Refugee Settlement, which hosts over 200,000 refugees, most of whom are women and children. The program will translate rights-based accountability for sexual and reproductive health and rights (SRHR) into practice in crisis settings.
The first phase of the intervention was initiated in March 2020 and currently has funding to continue until June 2021. Intervention costs have been covered by in-kind human resource (HR) contribution provided by CARE and both cash and HR in-kind contribution from CRR.
The partnership combines CARE Uganda’s experience implementing programs in humanitarian crisis and social accountability; CRR’s expertise on leveraging law and policy to implement progressive action for ensuring universal access to SRHR and increasing access to justice for women and girls experiencing reproductive rights violations; and both CARE and CRR’s combined prioritization towards applying the human rights framework to build accessible and responsive accountability mechanisms in humanitarian settings.
Why do we need rights-based accountability for SRHR?
Women and girls affected by humanitarian crisis have equal rights to comprehensive, essential and lifesaving sexual and reproductive health (SRH) services. But, within these settings there are complex challenges to ensuring the availability, accessibility, and acceptability of quality SRH services and information. This has resulted in disproportionately high rates of reproductive rights violations and poorer health outcomes among the affected women and girls who live there. An estimated 35 million women and girls aged 15-49 require humanitarian assistance and many have inadequate access to SRH services and information. Even before the onset of the COVID-19 pandemic, every day more than 500 women and girls in countries with emergency settings were dying during pregnancy and childbirth due to lack of quality SRH services.
While global processes and commitments have focused on strengthening accountability mechanisms in these settings, the voices of women and girls experiencing reproductive rights violations remain largely unheard. Moreover, there is far too little access to effective remedies for women and girls whose rights have been violated.
Programmatic interventions focusing on accountability require a continuous and transparent process for collecting, reviewing and responding to testimony of women and girls whose rights have been affected, and a system of follow-up and referrals that ensures adequate remedies.
This is challenging in any setting, but arguably the most challenging in a humanitarian setting where health and judicial systems are transitional, cut-off, or non-existent.
How does the rights-based accountability mechanism work?
The rights-based accountability mechanism is a new community-led intervention for ensuring accountability for equal access to comprehensive, quality and lifesaving SRH services for women and girls living in humanitarian settings in Uganda. A human rights-based approach prioritizes a broad and robust understanding of accountability to ensure that policymakers, decision-makers, and others who have an impact on affected individuals and communities are held responsible for their actions and decisions and that individuals whose rights have been violated have access to remedies.
For the past year, the mechanism has been tested among refugee and host women and girls in Pagirinya Refugee Settlement, district and local Ugandan government duty-bearers, humanitarian implementers and programming staff across Pagirinya Refugee Settlement, the District Health Office, the Refugee Desk and Community Development Office, and UN agencies.
The innovation encompasses three integrated and reinforcing community-led structures:
1. Community Council for SRHR with representatives from refugee and host committees collects and reviews complaints received from refugee and host women and girls in the settlement. The Council increases awareness about rights-based accountability and builds human rights literacy to ground complaints and feedback. The Council is comprised of women’s representatives from both refugee and host communities, to ensure their distinct SRHR issues are recognized and addressed, and to build a shared understanding of human rights and agency in both communities.
2. Ombudsperson is selected by the district level government and settlement-level duty-bearers and conferred a mandate to review complaints, give explanations for decisions taken, and facilitate access to effective remedy, if rights are violated. The Ombudsperson works in collaboration with the Council as an intermediary between the duty-bearers and rights-holders.
3. Community-based facilitators (CBFs) design and lead monitoring of SRHR outcomes and experiences and refer complaints and feedback to the Council. CBFs also monitor implementation of duty-bearer response after complaints are reviewed and decisions for action are taken.
The innovation has three distinct functions:
1. Collect, Review, Respond: A council of community representatives collect, review, and respond to SRHR complaints, which is used as a basis for generating locally generated solutions. If an independent review is needed, an ombudsperson is used as a high-profile community representative. To assess gaps in the provision of rights-based SRH care services, they can use a checklist of five accountability mechanisms:
- Ensuring Availability of Services
- Informed and Autonomous Decision Making
- Respect Users’ Privacy and Confidentiality
- Provide Non-Judgmental and Respectful Care for Users
- Facilitating Participation and Complaints
2. Implement: After determining rights are violated, a council of community representatives and an ombudsperson ensures access to effective remedies for SRHR violations. Trained community-based facilitators are also used to raise awareness about SRHR and help with counseling and referrals.
3. Monitor: Community-based facilitators and other health care providers monitor the implementation of remedies to ensure improved quality, access, and equity of care.
What is the Theory of Change?
Assumptions/Rationale
- Humanitarian service providers and women representatives understand reproductive rights as human rights and can think about SRHR issues in the settlements through a human rights lens
- There are meaningful ways to engage affected women and girls in the design and roll-out of the innovation
- Ugandan government duty-bearers have the capacity to select an independent third party responsible for transparent review of SRHR complaints
- There is an agile system so that when problems or limitations surface, the model can be adapted to be responsive to feedback
Inputs
- International human rights expertise
- Constitutional law expertise
- Networks and partnerships
- National, regional, and global expertise
Outputs
- Increased access to rights-based accountability mechanisms
- Increased ability to counsel and refer to rights-based accountability mechanism
- Increased ability of women and girls to meaningfully participate, make SRHR complaints, and claim rights
- Increased answerability of duty-bearers to respond and ensure access to remedies
- Improved integration of rights-based accountability across SRHR service provision
Impact
- Strengthened rights-based accountability for SRHR for refugees and host community women and girls in Pagirinya Refugee Settlement
- Increased enjoyment of SRHR by refugee and host community women and girls in northern Uganda
- Universal access to SRH services without discrimination ensured
- Gender discriminatory laws and policies challenged and changed
- Access to justice for reproductive rights violations increased
What were the early results of the accountability mechanism?
Early results demonstrate the community-led process created is an effective way of amplifying the voices of women and girls and ensuring access to an effective remedy when rights are violated. The program has successfully reached 5,155 crisis affected women and girls with SRHR information and access to the accountability mechanism. Through the accountability mechanism, it collected and reviewed over 50 complaints and feedback related to SRHR under the right to health, privacy, information, and non-discrimination. Some examples of complaints and remedies have included:
Lack of Adolescent Access to Menstrual Hygiene Kits: In response to a complaint about the marginalization of girls and adolescents from UNHCR’s Menstrual Hygiene Kit Distribution Program, the SRH Council directly advocated to UNHCR. This resulted in the agency committing to increasing the number and coverage of kit distribution for improved adolescent accessibility. Community monitors have followed up and found that there has been a longer-term sustained commitment of this implementation over the last four months.
Lack of Protections for the Right to Health: In response to a complaint about a lack of available confidential adolescent SRHR services and information, inaccessible medical equipment for women with disabilities, and disrespect and abuse by healthcare workers, particularly among refugee women, the ombudsperson convened with duty bearers, government, and health service providers. This has resulted in the District Health Office increasing their oversight and monitoring duties at the health center. Additionally, the facility in charge committed to a review of respectful maternity care policies and the use of right to health trainings to ensure non-repetition at the health center.
Denial of Antiretroviral Treatments (ART) to Refugee Women: In response to individual complaints about the denial of ART services to new refugees that enter the settlements, the accountability mechanism successfully reversed the introduced policy that limited ART access to the existing patients only and ensured access to quality supplies to refugees in the settlement.
Increased Unintended Adolescent Pregnancy: In response to a complaint about increased unintended adolescent pregnancy as a result of a lack of SRH services, harmful practices of early and forced marriage, and COVID-19 restrictions, the SRH Council and the ombudsperson advocated directly to sub-county government executives. Duty-bearers committed to revising by-laws to include strategies to promote and protect adolescent SRHR and prevent early forced marriage.
What’s next?
The CARE Uganda/CRR team is now seeking investment to continue the program into the next phase. This will focus on testing the scalability of the intervention by expanding the accountability mechanism across other settlements within Adjumani district. The results will be consolidated so that they can be used to raise visibility and confidence in the intervention among a wider audience. With this funding the next phase will:
- Develop a scaling plan to institutionalize the rights-based accountability mechanism across other settlements within Adjumani district.
- Develop a technical guide and report of pilot outcomes in Pagirinya settlement using the programmatic data to demonstrate how rights-based accountability mechanisms can promote and advance the SRHR of all women and girls.
- Organize convenings with community partners and key stakeholders that make up the accountability mechanism, to document lessons learned and advance joint strategies for advancing accountability for SRH services across Adjumani.
- Build institutional capacity and knowledge of human rights accountability across CARE Uganda programs.
- Identify and amplifying synergies with other social accountability programs and networks in northern Uganda, such as the Community Score Card pilot in Arua.
- Conduct advocacy with the Ugandan Ministry of Health and District Health Offices to build the political will necessary as the primary duty-bearers for health services in Uganda.
- Organize briefings with key UN Member States and agencies at the Human Rights Council, UN Security Council, and UN Headquarters; and at the African Union to promote States’ support of the importance of rights-based accountability in humanitarian response.
- Co-host engaging and accessible events with rights-holders, duty-bearers, and technical staff to raise visibility of the project expansion and leverage outcomes for global, regional and national advocacy.
Ultimately the goal is to continue to improve and expand the program over the next 3 years, to be in position to seek a larger investment to model and replicate the intervention in humanitarian contexts. It is through scaling the intervention that we will be able to better ensure a contribution to wider global goals of reducing maternal mortality, delivering universal health care, ending all forms of discrimination against all women and girls, reducing gender-based violence, protecting fundamental freedoms, and promoting non-discriminatory law and policy.