HWAI Advocacy Toolkit

8/10/2019 HWAI Advocacy Toolkit

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A resource developed for the Health Workforce Advocacy Initiative

Addressing the Health Workforce Crisis

ADVOCACY

TOOLKIT


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Advocacy Toolkit

The Health Workforce Advocacy InitiativeThe Health Workforce Advocacy Initiative (HWAI) is a broad-based network of civil society

organizations that work to realize a world where everyone has access to a skilled, motivated

health worker within a robust health system. Member organizations in the HWAI network work in

tandem to advocate for increased investment in human resources for health (HRH) on the country,

regional, and global levels. HWAI Members as of 2014 include:

Abt Associates; Accordia Global Health Foundation; ACOFEN; Act Now to Stop War and End

Racism (ANSWER); Action Group for Health, Human Rights and HIV/AIDS (AGHA); Africa Center for

Development Communication; Africa Health Placements; African Center for Global Health and Socia

Transformation; African Public Health Association (APHA); AMREF Health Africa; American College of

Healthcare Executives; American College of Nurse Midwives; American Heart Association; Association

pour la Solidarit et lAssistance Socio-Sanitaire; Bill & Melinda Gates Foundation; The Benjamin William

Mikapa HIV/AIDS Foundation (BMAF); BRAC; Brot Fuer Die Welt (Bread for the World); Brown University

CapacityPlus; CARE; Centers for Disease Control and Prevention; Center for Health Educationand Appropriate Health Technologies (CESTAS); Center for Health Sciences Training Research and

Development (CHESTRAD/ ACOSHED); Chicago CHW Local Network; Chor Unnayon Society; CleanBirth

org; Community of Health Research and Consultancy; Consbllio Nauomou Saude-Brasil; CORE Group;

Crigler Global Consulting; Development Organization of the Rural Poor (DORP); East, Central and

Southern Africa Health Community (ECSA-HC); Elizabeth Glaser Pediatric AIDS Foundation; Eminence;

Family Care International; Federacion Enformas; Foundation for the Advancement of Internationa

Medical Association and Research (FAIMER); FueSalud.Co; Glasgow Caledonian University; Globa

Alliance to Prevent Prematurity and Stillbirth (GAPPS); Global Health Systems Philanthropy; Globa

Health through Education Training and Services (GHETS); Global Health Workforce Alliance (GHWA);

Global Healthcare Information Network; Goal4.org; Health Alliance International; Health GAP; Health

Rights Education Programme (HREP); Health Poverty Action; Human Resources for Health Coalition;Helen Keller International; Hesperian Health Guides; IMA World Health; Instituto de Cooperacion

Social Integrare; Instituto Hondureno de Seguirdad Social; International Agency for the Prevention o

Blindness (IAPB); International Childrens Heart Foundation; International Confederation of Midwives;

International Council of Nursing; International Medical Corps; IntraHealth International; Jacaranda

Health; Jhpiego; Johns Hopkins School of Public Health; Malaria Consortium; Management Sciences

for Health; Medicins du Monde; Medicus Mundi International Network; McKinsey; McMaster University

Canada; Merlin; Ministry of Health Brazil; Ministry of Health-DRH/Santi-Mali; Ministry of Health, Sri Lanka;

Mutah Univeristy, Jordan; Non Communicable Diseases Forum (NCD-F); Northern Regional Alliance

One Million Community Health Workers Campaign; Pathnder International; Paths2 (Abt); Peoples

Health Movement (PHM Global); Physicians for Peace; Population Communication; Population

Services International (PSI); Prisma; Public Health Institute; The Regional Network for Equity in Health inSouthern Africa (EQUINET); Secretaria de Gestao do Trabalho-Brasil; RESULTS UK; ReSurge International;

Royal College of Nursing; Save the Children; Secretaria Saude-Tocaims Brasil; Shehu Idris College of

Health Sciences and Technology (SICHST) Makar, Kaduna State, Nigeria; Siertana de Saude do Olinda

PE-Brasil; South Africa Independent; Terre Des Hommes Germany; Training for Health Equity Network; The

Unions International Management Development Programme (IMDP); Universidad Nacional Autonoma

de Honduras; University of Utah, College of Health; University of Washington, HAI; University Research

Co.- Nutri Salud; Uttar Pradesh Health Systems Strengthening Project; VSO International; Wellshare

International; Wemos; White Ribbon Alliance for Safe Motherhood; WHO; Women and Health Alliance,

International; Womens Refuge Commission; The World Medical Association.


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Acknowledgements

This Advocacy Toolkit was developed by Sarah Roma, with contributions from the HWAI Capacity

Building for HRH Advocacy Working Group:

Heather Teixeira, IntraHealth International

Mary Mikhail, Global Health through Education, Training and Service (GHETS)

Laura Hoemeke, IntraHealth International

Deepanjali Jain, IntraHealth International

Stephan Rabimov, The Unions International Management Development Programme(IMDP)

Maziko Matemba, Health and Rights Education Programme (HREP)

HWAI would also like to thank those who contributed case stories for the toolkit: Zubaida Akbar (Save

the Children); Rebeca Berner (El Poder Del Consumidor); Christina Godfrey (Benjamin William Mkapa

HIV/AIDS Foundation); Maziko Matemba (Health and Rights Education Programme); Julia Robinson

(Health Alliance International); and Zubair Mohammad Shirzay (Save the Children).

This toolkit was based on an earlier version created by HWAI members:

Pat Daoust, Physicians for Human Rights

Lisena DeSantis, Physicians for Human Rights

Eric Friedman, Physicians for Human Rights

Sarah Kalloch, Physicians for Human Rights

Jirair Ratevosian, Physicians for Human Rights

Emily Bancroft, Action Group for Health, Human Rights and HIV/AIDS (AGHA) Uganda

Dr. Nelson Musoba, Action Group for Health, Human Rights and HIV/AIDS (AGHA) Uganda Paul Davis, Health GAP (Global Access Project)

Jennifer Flynn, Health GAP

Dr. Jen Cohn, University of Pennsylvania

Anne Sosin, Johns Hopkins School of Public Health

Dr. Ambrose Agweyu, Medical Intern, Bungoma District Hospital, Bungoma, Kenya

Produced 2014


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ContentsCHAPTER 1: INTRODUCTION .......................................................................................................................................5

Purpose of this Toolkit and Who it Is For ............................................................................................................5

How the Toolkit is Organized .............................................................................................................................5

CHAPTER 2: INTRODUCTION TO ADVOCACY ...........................................................................................................7

What is Advocacy? ............................................................................................................................................7

The Importance of Advocacy in Solving the Global Health Workforce Crisis .............................................7

Advocacy and Related Concepts ..................................................................................................................8

Assessing Your Advocacy Capacity ................................................................................................................9

Tool: Advocacy Capacity Assessment ..........................................................................................................11

Steps in the Advocacy Planning Process ......................................................................................................12

HWAI Advocacy Planning Cycle ....................................................................................................................12 Factors Shaping an Advocacy Strategy .......................................................................................................13

CHAPTER 3: UNDERSTANDING THE CONTEXT ..........................................................................................................15

Global Overview ..............................................................................................................................................15

Understanding the HRH Context in Your Country .........................................................................................17

CHAPTER 4: DEFINE THE PROBLEM AND ADVOCACY ISSUE ..................................................................................21

Dening the Problem, Solution, and Advocacy Issue ..................................................................................21

Tool: Problem and Solution Tree ......................................................................................................................22

Tool: Choosing an Advocacy Issue Checklist ...............................................................................................23

CHAPTER 5: DEVELOP ADVOCACY GOAL AND OBJECTIVES ................................................................................25

Tips for Developing Advocacy Goals and Objectives ................................................................................25

Example Advocacy Goal and Objectives ....................................................................................................26

Case Story: National Orientation Practice for Newly Recruited Health Workers in Tanzania ..................27

CHAPTER 6: BUILD PARTNERSHIPS ............................................................................................................................29

The Importance of Engaging Others .............................................................................................................29

Benets and Challenges of Working with Others ..........................................................................................30

Tips for Developing Coalitions .........................................................................................................................31

Case Story: The NGO Code of Conduct for Health Systems Strengthening .............................................32

Tool: Partnership Mapping ...............................................................................................................................33

CHAPTER 7: GET THE FACTS ......................................................................................................................................35

Why Gather Evidence? ...................................................................................................................................35

Information Gathering .....................................................................................................................................36

Case Story: Malawis Global Human Resources for Health Commitment.................................................38

Tool: Mapping Evidence ..................................................................................................................................41


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CHAPTER 8: UNDERSTAND THE POLICY PROCESS ...................................................................................................43 Understanding the Policy Context .................................................................................................................43 Understanding Power ......................................................................................................................................43 Inuencing Health Budgets .............................................................................................................................44

Example Policy Process Map ..........................................................................................................................45

Case Story: The Mexican Tax on Sugar Sweetened Beverages: A Victory in Progress ............................47

Tool: Policy Process Map ..................................................................................................................................50

CHAPTER 9: IDENTIFY AND ANALYZE TARGETS .......................................................................................................52 Identifying Your Targets ....................................................................................................................................52 Analyzing Your Targets .....................................................................................................................................54

Case Story: A Community Advocates for Local Level Health Coverage in Afghanistan .......................55

Tool: Identifying Primary and Secondary Targets ..........................................................................................57

Tool: Stakeholder Mapping .............................................................................................................................58

CHAPTER 10: DEVELOP AND DELIVER MESSAGES ...................................................................................................60 Advocacy Messaging ......................................................................................................................................60 Message Delivery and Channels of Communication ..................................................................................60 Engaging Mass Media for Advocacy ............................................................................................................61

Example Public Testimony: HWAI Statement at the 2014 World Health Assembly ....................................63 Using Social Media for Advocacy ..................................................................................................................64

Example Tweets for World Health Worker Week ...........................................................................................65 Lobbying and Communication with Decision-Makers ................................................................................66

Tool: Message Development ..........................................................................................................................69

CHAPTER 11: DEVELOP AND IMPLEMENT ACTION PLAN ........................................................................................71 Choosing Advocacy Tactics and Actions .....................................................................................................71 Identifying Moments of Opportunity ..............................................................................................................72 Developing the Action Plan ............................................................................................................................72

Example of the Importance of Timing: AIDS Drugs for Africa......................................................................73

Tool: Action Plan ...............................................................................................................................................74

CHAPTER 12: MOBILIZE RESOURCES ........................................................................................................................76 Budgeting and Getting Resources for Advocacy Work ..............................................................................76 Legal Issues in Fundraising for Advocacy ......................................................................................................76

CHAPTER 13: MONITOR, EVALUATE AND LEARN.....................................................................................................77

Tips to Address the Challenges of Monitoring and Evaluating Advocacy Work ......................................77 Five Questions for Planning Advocacy Monitoring and Evaluation ...........................................................78 A Sample Advocacy M&E Framework ..........................................................................................................79

Tool: Monitoring and Evaluation Plan.............................................................................................................80

APPENDIX 1: ADVOCACY STRATEGY TEMPLATE .....................................................................................................81GLOSSARY OF ADVOCACY TERMS .........................................................................................................................87ADDITIONAL ADVOCACY RESOURCES ...................................................................................................................88HWAI RESOURCES .....................................................................................................................................................90


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Advocacy ToolkitADDRESSING THE HEALTH WORKFORCE CRISIS

Chapter 1: IntroductionPurpose of this Toolkit and Who it Is For

The purpose of this toolkit is to assist health professionals, health professional associations, and civil

society organizations to translate rsthand experience and technical knowledge into effective

advocacy strategies to inuence human resources for health (HRH) policies at local, national,

regional and global levels.

How the Toolkit is Organized

This toolkit is organized into chapters that correspond to the basic steps of developing an advocacy

strategy. Each chapter contains explanations of key advocacy conceptsand specic tools to help

you plan your advocacy work. The chapters may be used independently or used together to

create one overarching advocacy strategy. The actual process of developing an advocacy

strategy is rarely linear. This toolkit is meant to be a basic guide, but you will likely move back and

forth between chapters and steps as needed to meet your needs. All of the individual tools through-

out the chapters willwhen put togethercomprise your overall advocacy strategy (see Appendix

1: Advocacy Strategy Template).

Because the policy and advocacy environment in each country or region is different, this toolkit

contains exible and adaptable tools that advocates can use to develop their own targeted

strategies, and to affect the change most needed in a specic context. The information in this

toolkit provides a general background and adaptable tools and techniquesit is up to you to

put this toolkit into action, identifying your countrys needs, your solutions, and how to make

them happen.

Throughout the toolkit, the following iconswill draw attention to specic examples and tools to help

you understand and plan for advocacy:

Case Story or Example

This icon is used to denote case stories or examples that illustrate advocacy in action.

Tool

This icon is used to mark specic templates and worksheets to help you plan for

your advocacy work.


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Photo courtesy of IntraHealth International


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Chapter 2: Introduction to AdvocacyWhat is Advocacy?

HWAI denes advocacyas a deliberate process based on evidence and experience, directed at

impacting the policies, positions, or programs of inuential institutions in order to create systemic

and long-term solutions to the HRH crisis. There are many denitions of advocacy and many

contexts in which advocacy can be used, but this toolkit is specically concerned with inuencing

policy changes.

There are a range of approaches to advocacy, some of which are confrontational, while others

involve collaboration, education, outreach, meetings and more collegial approaches to changing

power and policy dynamics. Each advocacy strategy will depend on the specic issues and context.

The most important thing is to lend your voice, your expertise, and your passion to making change

that is the essence of advocacy.

The Importance of Advocacy in Solving theGlobal Health Workforce Crisis

Health workers are necessary for the delivery of essential health services for maternal and child

health, HIV/AIDs, tuberculosis, malaria treatment, family planning, noncommunicable disease treat-

ment and prevention, and other global health issues. A lack of investment in HRH has been identied

as a major barrier to achieving both robust health outcomes and universal health coverage (UHC).

HWAI member organizations recognize the need for advocacy in order to inuence policies that

will create systemic and long-term solutions to the HRH crisis. Members advocate at local, national

and globallevels to increase investment and political will to address

the crisis-level global health workforce shortage, a necessity forsustainable progress on critical health issues.

In order to achieve a world where everyone has access to a skilled,

motivated health worker within a robust health system, HWAI

advocates to inuence and galvanize support for strong global

and regional level health workforce policies, including through

global compacts like the Sustainable Development Goals. HWAI

members further advocate at national and local levels, to inuence

governments to strengthen their health workforce policies, and then

to hold them accountable to commitments they have made to

improve HRH. HWAI also advocates for the implementation of the

WHO Code of Practice on the Migration of Health Personnel, a land-

mark code of practice outlining the ethical recruitment of health

workers. Additionally, HWAI advocates for the inclusion of health

workforce language and focus within different vertical global

health issue areas, such as HIV/AIDS and maternal and child health.

Importantly, this advocacy has led to increased political will and

funding for HRH, resulting in very real positive health outcomes for

people all over the world.

Advocacy

A deliberateprocess based on

evidence andexperience,directed at

impacting thepolicies, positions,

or programs ofinuential

institutions inorder to createsystemic and

long-termsolutions to the

human resourcesfor health

(HRH) crisis.


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Advocacy and Related Concepts

What Advocacy Is and Is Not: A Comparison of Advocacy and Related Concepts

Advocacy is often confused with other approaches that share common elements. To achieve

a clearer understanding of what advocacy is, it is helpful to clarify what advocacy is not. All of

these related concepts may be tactics within an advocacy strategy, but would not be considered

advocacy in and of themselves. Use the chart below to compare and contrast advocacy with

related concepts.

CONCEPT OBJECTIVE TARGET AUDIENCE TYPICAL TACTICS

Advocacy Development, change, Policy-makers Lobbying, community

and/or implementation and other key mobilization, coalition building

of policies; change in decision-makers/leaders. mobilizing stakeholders, public

resource allocation relations, IEC, research,

use of media, etc.

COMPARING SIMILARITIES AND SIMILARITIES AND SIMILARITIES AND

ADVOCACY TO: DIFFERENCES IN DIFFERENCES IN DIFFERENCES IN

OBJECTIVES TARGET AUDIENCE TYPICAL TACTICS

Information, An IEC approach seeks to The target audience of IEC Typical tactics of IEC include

Education, raise awareness and is individuals and segments material development and

Communication increase understanding of a community (men, dissemination, use of multiple

(IEC) among its target audience. women, and youth). media channels, and

Although an advocacy Although an advocacy workshops and trainings.

strategy may raise awareness strategy may have Advocacy may use IEC as

as one of its tactics, it will some of these same one of its many tactics to

always ultimately seek to audiences as its secondary raise awareness, but would

develop, change, and/or targets, the primary target not stop at just raising

implement policies and/or audience of an advocacy awareness. IEC would be

change resource allocation. strategy must always be part of a larger strategy,

a decision-maker. involving multiple tactics

to inuence policy decisions.

Public Relations Public relations strategies seek The primary target audience Typical tactics of publicto improve the organizations of a public relations strategy relations include advertising,brand, image, and support is typically donors, general outreach to stakeholders,and increase program coverage public and stakeholders, and media outreach forand credibility. Although an media, community leaders, coverage. Advocacy mayadvocacy strategy may also try and other nongovernmental use public relations and manyto increase credibility and support organizations (NGOs). of these same activities asas one of its tactics, it will always Although an advocacy one of its many tactics to

ultimately seek to develop, change, strategy may have some increase credibility andand/or implement policies and/or of these same audiences, support, but would not stopchange resource allocation. the primary target audience there. Public relations would

of an advocacy strategy must be part of a larger strategy,always be a decision-maker. involving multiple tactics to

inuence policy decisions.

1Castro, Maria Antonieta Alcalde, and Gabriela Cano Azcrraga. 2010. Handbook for advocacy planning. New York, NY: InternationalPlanned Parenthood Federation, Western Hemisphere Region.

https://www.ippfwhr.org/sites/default/les/Advocacy%2520Planning%2520web%2520version.pdf (accessed December 3, 2014).


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Assessing Your Advocacy Capacity

Advocacy requires specic capacities at both an individual and organizational level, and it isimportant to have a realistic understanding of what capacities you have, and what needs strength-

ening. You do not have to be an expert in every area in order to undertake advocacy, but the more

capacity you and your organization have, the more chances you have of being successful in your

advocacy efforts. Part of effective advocacy includes continued capacity-building, and once you

have a sense of where you may need to strengthen your capacity, it is important to plan for how you

will do this, and also how you will monitor progress.

Individual Capacity:Individual advocates need the ability to work in the following areas:

Understand and analyze the larger context: Assess the larger context, understand problems and

what is causing them, and develop and assess possible solutions.

Conduct and share policy research and analysis:Undertake policy research and analysis

to assess the policy environment and generate evidence about and analyze specic policy

problems and solutions. The evidence generated from policy research must also be interpreted

and communicated at the correct time to the relevant audiences and in the appropriate

manner. That means using the best format so that the knowledge is clearly communicated,

can be absorbed, and will have the desired impact.

Community Community mobilization seeks The primary target audience Typical tactics of community

Mobilization to build a communitys of community mobilization mobilization include organizingcapacity to rank needs and strategy is typically community and conducting communitytake action. Although an members and/or leaders. meetings, workshops, etc.advocacy strategy may also Community mobilization Advocacy may use communitytry to build a communitys may or may not target a mobilization as one of itscapacity to take action as decision-maker, but when many tactics to mobilize aone of its tactics, it will it does may overlap with community towards its goalalways ultimately seek to advocacy. However, the and objectives, but woulddevelop, change, and/or primary target audience of not stop there. Communityimplement policies and/or an advocacy strategy must mobilization would be partchange resource allocation. always be a decision-maker. of a larger strategy, involving

multiple tactics to inuencepolicy decisions.

Lobbying Similar to advocacy, Similar to advocacy, the Typical tactics of lobbying

lobbying seeks to change primary targets of lobbying include meetings, conferences,opinions, gain support, include policy-makers petitions, and dinners/and convince a specic and other key decision- receptions. Advocacy maypolicy-maker to take action makers/leaders. use lobbying as one of its many

or address an issue. However, tactics to convince decision-this is the sole objective of makers to take action, but thelobbying. An advocacy lobbying would be part of astrategy may employ larger strategy, involvinglobbying as one of its many multiple tactics to inuencetactics, but would also involve policy decisions.a broader strategy beyondjust seeking to convincedecision-makers.


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Understand, analyze, and navigate the policy and political landscape:Understand and

analyze the policy process and political environment to assess when and how to inuence

it and respond to changes.

Identify, analyze, and inuence key targets:Understand and analyze relevant decision-

makers in order to build relationships and inuence. Navigating relationships with decision-

makers necessitates understanding the dynamics of power and having the capacity to engage

them through multiple platforms.

Develop and deliver advocacy messages:Develop, tailor, and communicate advocacy

messages through multiple channels and with multiple audiences.

Work with others: Work with key allies and partners, including relevant coalitions, networks,

and other public constituencies.

Plan and implement an action plan:Strategically plan for advocacy activities and tactics,

including an understanding of how to assess timing and required resources; and capitalize

on key windows of opportunity for action.

Monitor, evaluate, and learn:Monitor, evaluate, and learn from advocacy and incorporate

learning to inform current and future advocacy efforts.

Organizational Capacity: In order to be most effective in their advocacy work, organizations

should have:

Synergy with organizational vision: Is advocacy part of the organizations mission, vision, and/or

theory of change? Is there strong leadership in the organization for advocacy, including support

from senior management? Is there a clear understanding of advocacy across the organization?

Sufcient resources:is the organization actively seeking ways to mobilize additional resources for

advocacy, both nancial and nonnancial (e.g., time, skills, and knowledge)?

Organizational processes: These may include deliberate mechanisms to help the organization

plan, monitor, evaluate, and learn from advocacy work; coordinate advocacy efforts across

various program areas and/or departments; integrate advocacy into resource mobilization

efforts; and build and sustain advocacy capacity.

Credibility with governments and other partnersIs your organization perceived as objective,

trustworthy, and politically neutral?

2Cohen, David. 2010. Essay on Advocacy. NY, New York: Encyclopedia of Social Sciences, Sage Publications Inc.Print (accessed Dec. 1, 2014)


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Tool: Advocacy Capacity Assessment

On a scale of 1 (no capacity) to 5 (expert), rate each of the individual and organizational capacities

listed in the table below to determine where you may need to strengthen your capacity. To see this

visually, plot your ratings on a spider diagram like the example below.

Individual Understand and analyze the larger context

Conduct and share policy research and analysis

Understand, analyze, and navigate the policy

and political landscape

Identify, analyze, and inuence key targets Develop and deliver advocacy messages

Work with others

Plan and implement an action plan

Monitor, evaluate, and learn

Organizational Fit with organizational vision

Resources

Organizational processes

Credibility

Individual Capacity Rankingor Please check one

Organizational number on a scale of 1(no capacity) to 5 (expert)

1 2 3 4 5


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Steps in the Advocacy Planning Process

Advocacy is rarely an orderly and linear process and, as a result, is often conducted in an ad hoc

way, responding to opportunities as they arise. This toolkit is intended to help you plan for your

advocacy work more strategicallyto ensure that you have the greatest possible impact on the

policies you are trying to inuence, and so that you use your time, energy, and resources as effec-

tively as possible. The following are a series of advocacy planning steps to provide aframework to

help you develop an advocacy strategy. Although these steps might not always occur in the same

order and are often iterative, each step is an integral piece of planning for your advocacy work. The

following chapters will describe each of the planning steps in greater detail and provide specic tools

to help you plan. All of these tools will then t together to comprise your overall advocacy strategy

(see: Appendix 1: Advocacy Strategy Template).

HWAI Advocacy Planning Cycle


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Factors Shaping an Advocacy Strategy3

Advocacy and the kind of strategy you develop will be shaped in large part by your context, the

timing, and the risk involved. It is important to consider some key factors at the outset:

Context:Every political environment is different. Each presents its own opportunities andconstraints. Governments have varying degrees of legitimacy and power vis--vis civil society, the

private sector, and transnational and international organizations and institutions. Political decisions

are made differently depending on the nature of the state, politics, media, and civil society. In

some places, the legislature has more authority. In others, the Minister of Finance dominates poli-

cy-making. Countries have different levels of freedom and access to the public sector. People use

these opportunities differently depending on literacy, poverty, and social relationships. A societys

mix of culture, religion, ethnicity, race, and economic development affects the level of tolerance

and openness to social change. In some countries, advocacy at the local or the international

level may be more feasible than at the national level. (For more information on assessing the

political environment and players, see Chapter 8: Understand the Policy Process and Chapter 9:

Identify and Analyze Targets).

Timing:Each historic moment presents distinct political opportunities and constraints. International

economic trends may make a country tighten or expand political space. Elections or internationa

conferences may provide opportunities to raise controversial issues. At some moments, a march

or demonstration will draw attention to an issue. At others, a march may provoke repression.

Risk: Not all advocacy strategies can be used universally. In some places, a direct action aimed

to reach a key decision-maker may be politically dangerous, or may lessen the potential for

long-term change. In some countries, pushing for change that affects cultural beliefs may

provoke a backlash. Challenging relationships of power often generates conict and advocates

must have ways of dealing with this without taking unnecessary risk. In more closed environments

advocacy often takes the form of community action around basic needs and is not publicly

referred to as political advocacy. Whatever the context, sometimes risks need to be taken

because there are no other options. In these cases, everyone involved must understand the

implications of those risks.

3Miller, Valerie. 1994. NGOs and grassroots policy inuence: What is success? Institute for Development Research, Vol. 11, No. 5 1994.


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Paul Joseph Brown/ GAPPS


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Chapter 3: Understanding the ContextAn essential prerequisite to any advocacy planning is having an in-depth understanding of the

overall context of the issues and environment in which you are working. Advocacy on HRH issues

will require both an understanding of the global context of HRH and the specic HRH situation and

challenges to address in your particular country and environment. The following sections provide a

big-picture overview of HRH and the current global landscape and provide guiding questions to help

assess the HRH situation in your own country context.

Global OverviewThe World Health Organization (WHO) denes a health worker as all people engaged in actions

whose primary intent is to embrace health. This denition includes doctors, nurses, midwives, and

community health workers (CHWs), but also includes support workers such as public health profession-

als, pharmacists, and others.

Health workers are the backbone of health systems. National and global efforts to achieve ambitious

improvements in health outcomesincluding a push to end preventable maternal and child deaths

and reach the goals of an AIDS-free generation and UHCcannot be realized in the absence of anadequately equipped, trained, and supported health workforce.

In the report A Universal Truth: No Health Without a Workforce, the Global Health Workforce Alliance

(GHWA) and the WHO estimate a gap of 7.2 million health workers in 2012, set to rise to 12.9 million

across the next decade. In 2012, the majority of countries below the WHO threshold of 22.8 skilled

health workers per 10,000 population and with a coverage of births by skilled birth attendants below

80% were in sub-Saharan Africa (31 countries, 57.4%) followed by Southeast Asia (7 countries, 12.9%).

Although most countries with available data have shown growth in the number of midwives, nurses,

and physicians since 2004, this growth has not kept pace with population growth, demographic

changes, and a shifting disease burden.

Some countries, however, are beginning to demonstrate the far-ranging impact that investmentin health workers can create. Ethiopia, for example, was able to reduce by more than two-thirds

their under ve mortality rate and achieve MDG 4. Through their health extension worker program,

the Ethiopian government has dramatically increased the provision of health services to its rural

population. Since 2003, more than 38,000 government salaried health extension workers, the

majority of them young women, have been deployed to over 15,000 health posts right across

the country. This expansion of services is frequently credited with the success Ethiopia has had

in reducing child mortality.

Challenges to achieving a sustainable workforce are numerous and varied. In Universal Truth: No

Health Without a Workforce, GHWA and other partners highlight some of the HRH development

challenges, including:

The health workforce is aging, and replacing retired health workers is often difcult because of

worker shortages, governmental policies, and lack of recruitment incentives.

The aging of the health workforce is of particular concern in high-income countries, demonstrat-

ing that although low- and middle-income countries have a more acute health workforce gap,

4Campbell, J.G. Dussault, J. Buchan, F. Pozo-Martin, M. Guerra Arias, C. Leone, A. Siyam, and G. Cometto. A universal truth: No health with-

out a workforce. Forum Report, Third Global Forum on Human Resources for Health, Recife, Brazil. Geneva: Global Health Wofkroce Allianceand World Health Organization, 2013. http://www.who.int/workforcealliance/knowledge/resources/GHWA_AUniversalTruthReport.pdf52013. Ethiopia meets MDG 4 by cutting Under 5 mortality By Two-Thirds Since 1990 Unicef-Ethiopia. http://www.unicef.org/ethiopia/

events_13459.html (accessed December 3, 2014)6World Health Organization, Regional Ofce for Europe. Health workforce data and statistics 2014. http://www.euro.who.int/en/health-topics

Health-systems/health-workforce/data-and-statistics (accessed Dec. 3, 2014)


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HRH issues are important globally. In Denmark, France, Iceland, Norway, and Sweden, where

fewer and fewer health professionals are entering the workforce, the average age of employed

nurses is 41-45 years.

Skills-mix imbalances persist and advanced practitioners, such as clinical ofcers, are used

inefciently in many settings.

Task shifting is an effective and important policy option to reduce health workforce shortagesand skills-mix imbalances. Task shifting, as dened by the WHO, involves the rational distribution of

tasks among health workforce teams. In middle- and low-income environments, task shifting often

involves the transfer of appropriate tasks to workers with less specialized training. Examples include

the utilization of CHWs to provide basic HIV/AIDs treatment and care in several countries in

sub-Saharan Africa. Studies indicated no difference in patient outcomes between those treated

in community-based settings by lesser trained providers, such as CHWs, and those receiving the

same treatment by higher trained professionals in clinical settings.

There is often inequitable geographic distribution of health workers within countries due to

difculties in recruiting and retaining workers to work in more remote settings.

Many countries suffer from an uneven distribution of health workers, with a high concentration of

workers in urban areas and an acute shortage in rural areas. Health professionals settle in urbanareas because of convenience, better opportunities for themselves and their families, and gener-

ally better equipped facilities. There are several policy options to address this disparity including

nancial incentives, professional development opportunities, and nonnancial incentives.

Attrition of health workers due to migration out of the country exacerbates shortages,

particularly in low-resourced countries and areas with the greatest need.

Out-migration of skilled health workers further increases the shortage in many low- and middle-in-

come countries. Several causes of out-migration have been identied including the lack of

options for career and professional development, poor management, and a heavy workload

There is often a lack of an enabling environment to encourage retention, productivity,

and performance of health workers.An enabling environment for health workers has been shown to improve health worker engage-

ment in the delivery of quality care. Evidence has shown that several key variables impact health

worker performance and productivity and thus affect the quality of services delivered and the

improvement in health outcomes. These key variables include clear health worker roles and

performance expectations, supportive supervision, regular feedback, career path opportunities,

incentive structures (nancial and nonnancial), objective performance evaluations, and safe

and enabling working environments. Many countries, particularly low-resourced countries, do not

offer these support systems to health workers.

There is a need for strengthened human resources information data and systems for

decision-makers.

Strengthened systems for data collection and reporting mechanisms will allow monitoring and

evaluation of HRH development and its impact on health outcomes. Up-to-date and compre-

hensive information on HRH is essential for effective management and decision-making on health

workforce issues. However, not all countries have an accurate account on metrics related to the

health workforce, and indicators, such as quality of care, are often ignored entirely.

7World Health Organization. 2008. Task Shifting: Global recommendations and guidelines. Geneva, Switzerland: World Health Organization.http://www.who.int/healthsystems/TTR-TaskShifting.pdf8 Buckley, G.J.; Lange, J.E.; Peterson, E. A. 2014 Investing in global health systems sustaining gains, transforming lives. Institue of Medicine

of the National Academies, The National Academies Press, Washington DC9Fulton, B; Schefer, R; Sparkes, S; Auh, E.Y.; Vujicic, M; Soucat, A. 2011 Health workforce skill mix and task shifting in low income countries: a

review of recent evidence Human Resources for Health. 9:1


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Efforts to build the capacity of the health workforce and to support health workers need to be multi-

sectoral and consistently implemented over the long-term. HWA found that countries that have

demonstrated progress towards reducing their health worker decit have several commonalities:

An integrated approach to improve human resources for HRH by linking together workforce

development initiatives and broader health systems strengthening actions

Demonstrated continuity in the implementation of their health workforce development

strategies

Sustained political will and commitment to bolstering the health workforce, demonstrated through

targeted policies and investment of nancial resources.

For more information about the global health workforce, please use the following resources

(for more resources, please see the list of HWAI Resources at the end of this toolkit):

The Global Health Workforce Alliance (GHWA)

http://www.who.int/workforcealliance/en/

The WHO Ofce for Health Systems

http://www.who.int/healthsystems/en/

The Alliance for Health Policy and Systems Research

http://www.who.int/alliance-hpsr/en/

Health at the World Bank

http://www.worldbank.org/en/topic/health

Understanding the HRH Context in Your Country

Countries have their own unique context and HRH challenges to address. Developing an effec-tive national advocacy strategy requires an understanding of the country context. Below are a list

of questions to guide your initial research and conversations with policy-makers, stakeholders, and

community members and leaders. For a fuller discussion of the importance and process of gathering

evidence, please see Chapter 7: Get the Facts.

Government Plans and Policies on HRH

Are health workforce strengthening activities included in your countrys strategic plan for health?

Does your country have a specic health workforce development plan?

Are government policies on health workforce development consistent across various plans and

ministries? If there are inconsistencies, what are they? If your country has an HRH development plan, is it funded? Is it currently being implemented?

What position is responsible for the implementation at national and subnational levels? How

does that position disseminate updates on progress? What are the reporting and accountability

mechanisms?

What bodies are responsible for developing and enforcing the norms and standards for health

worker cadres, including pre-service education curricula, licensing and registration requirements,

tracking of licensing renewals, and regulatory oversight? What are the reporting/enforcement

mechanisms for these bodies?


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What are some specic policies that attempt to stem attrition of health workers? Do they address

salaries and benets, working conditions, professional development, and supportive supervision?

How are they implemented? Is there a mechanism in place to monitor and evaluate the impact/

effectiveness of retention strategies?

Are there specic policies that govern the deployment of health workers? How are they

implemented?

What policies are in place to increase access to and the utilization of health services, especially

among underserved groups? How are they implemented? Is there a process for measuring the

effectiveness of these policies?

Does the government have structures in place to enable health workers and nongovernmental

organizations (NGOs) to contribute to health workforce planning and monitoring

and evaluation?

Health Workforce Accounting

How does the government track the number of health workers? If tracked, what are thenumbers of health workers (physicians, nurses, midwives, community health workers) present

in your country, state, and/or community?

What is the gap between the health workers that are present and employed and the number

needed to deliver essential health services?

Is there an up-to-date account of the licensed and registered health workers in each cadre?

If so, how many are there in the country, region, or district?

Has the government utilized tools or technologies to map health workers and support them in thei

work? This might mean utilizing human resources information systems (HRIS) or putting in place an

HRH Observatory.

Health Financing

What percent of the gross domestic product goes towards health expenditure? How much of

this expenditure is out of pocket?

Has your country estimated the total funding needed to provide everyone with access to

essential health services? What is the gap between the estimate and current spending?

How much of the health budget goes toward HRH?

Does your country receive multilateral, bilateral, or other outside aid? What percentage of

the health budget comes from international aid? How much of this money is spent on HRH

strengthening? Are programs implemented by international donors streamlined within the Ministry of Health in

your country? If not, what effect is that having on health workers in the public sectors?

Have there been budgetary decisions over the past few years that have signicantly altered

the ability to recruit health workers (i.e., a hiring freeze)?

Are there wage ceilings or health sector budget ceilings? How does the government justify

these ceilings?


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Production, Retention and Deployment of Health Workers

Does your country have a signicant problem related to health worker attrition? If so, what is

the cause?

Does your country have signicant disparities in access to and utilization of health services?

Do these disparities break down geographically between certain populations?

How many professional schools or universities are there that train health workers? Where are these

schools located? How many licensed /certied professionals do these schools graduate?

Is your country increasing the number of health workers educated in pre-service educational

institutions? If it is expanding, is the quality of training being maintained? Is there an accreditation

process in place?

How are health workers compensated? Are they compensated by the government or NGOs?

Is compensation scaled or are there added benets for health workers in more remote or less

desirable locations?

What are some of health workers biggest concerns in their place of employment? Is it safety frominfectious diseases, violence from the community, lack of adequate supplies, or unsafe working

conditions?

Are students recruited from rural areas for health professional training? Is the health worker recruit-

ment process perceived as being fair and transparent?

Are incentive packages in place to retain health workers, especially in rural areas?

Are CHWs and mid-level health workers such as clinical ofcers being used to help ll skills gaps

and address shortages, especially in rural areas?


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Chapter 4: Dene the Problem and Advocacy IssueDening the Problem, Solution and Advocacy Issue

Once you understand the overall context of HRH globally and in the context of your country, the next

step is to dene a specic problem that you think is critical to address, and then identify the specic

causes of that problem in order to help you decide which advocacy issue to focus on. As you

assessed the context of HRH in your country in Chapter 3: Understanding the Context, you may have

already identied some clear problems that you think are important to address. Using the Problem

and Solution Tree Tool can help you more thoroughly analyze the causes and consequences of the

problem and possible solutions.

Most problems are quite complex, and have many interconnected

causes and consequences. Among the many causes, you will want

to make sure that you consider if there are specic policy barriers

that are causing this problem. For instance:

What relevant policies exist/dont exist and what is needed:

o A new policy?

o Change in an existing policy?

o Enforcement or implementation of an existing policy?

o Resources?

After you have identied some specic causes of your problem, the

next step is to gure out possible solutions and which one to focus

on. It will be important to assess which causes and solutions maybe addressed by using advocacy to inuence policies, positions,

or programs of inuential institutions. These are your possible

advocacy issues. For instance, you might have identied health worker attrition as a problem in your

country. You may have further identied one of the many causes to be the lack of a national HRH

strategic plan that takes a comprehensive approach to addressing the health workforce shortage.

Thus, one solution and advocacy issue you might consider is how to get a national HRH strategic plan

in your country.

An organization should choose issues that are aligned with their mission and values and have

resources, value-add, and a chance of success. Once you have identied several possible

advocacy issues, the Choosing an Advocacy Issue Checklist Tool will help you think throughvarious criteria to help determine what issue to work on.

The Importanceof Evidence

It is critical to gather

specic evidence of the

problem and its causes,

consequences, and

possible solutions.

This is discussed more

fully in Chapter 7:

Get the Facts.


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Tool: Problem and Solution Tree

1. List the central problemthat you wish to analyze on the trunk of the tree.

2. Brainstorm a list of the causesof the problem and write them on the roots. To get to the real

roots of the problem, keep asking yourself WHY?

3. Brainstorm a list of the consequences of the problem and write them on the branches.

4. Discuss the interconnectionsand how various causes are related.

5. Highlight which causes may be addressed by using advocacyto inuence policies, positions,

or programs of inuential institutions.

6. Turn the causes of the problem into solutions. For example, if the problem is health workforce

attrition and one of the causes is that government spending on the health sector is lower than

the 15% that is needed, one solution, and your advocacy issue, would be to convince the

government to commit to increasing the health sector budget.

7. As a next step, for each possible advocacy issue you have identied, you can use the

Choosing an Advocacy Issue Checklist Tool to assess if your organization is well placed

to work on a particular advocacy issue.

Consequences

Problem

Cause


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Tool: Choosing an Advocacy Issue ChecklistFor each advocacy issue that you are considering working on, please consider the following criteria

to help determine if you are well positioned to move forward with advocating on this issue.

Advocacy Issue:

Criteria to Consider Comment Does it Meet the

Criteria? (yes/no)

The issue is relevant to the

organizations or coalitions

mission and strategies.

The issue is important to the people

that you are working with and

they have identied it as a priority.

Your organization is well placed

to work on this issue and has

something to add.

Documentation and research

are available.

You have a clear position on the issue

and a positive alternative that you

can communicate.

There is a chance for success.

The timing is right and there are

strategic opportunities for inuencing.

There are few and/or carefully

considered risk factors to people

and/or your program.

There are opportunities to buildstrategic alliances.

You have adequate resources

and staff.


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Courtesy Jhpiego/ Kate Holt


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Chapter 5: Develop Advocacy Goal and ObjectivesOne of the most important, but also most difcult aspects of

developing an advocacy strategy is setting a clear and strong

goal and measurable objectives. An Advocacy Goaldescribes

your vision and what you want to accomplish in the long-term,whereas your Advocacy Objectivedescribes the smaller, more

specic policy changes that you wish to accomplish. Coming to

consensus on the goal and objectives can take a considerable

amount of time and effort, especially when you are trying to

address a broad and complicated issue like the health workforce.

Now that you have dened the problem and advocacy issue,

you will focus on rening these issues into clear attainable goals

and objectives for a successful advocacy initiative.

Tips for Developing Advocacy Goals

and Objectives

1. Make sure your objectives include clear policy changesand that

you identify whoshould make the change, by how much, and

by when.

2. Your advocacy concerns may be too broad to be contained

in one single venture. Do not hesitate to consider having 2-3

advocacy objectives per goal.

3. Frame goals and objectives in terms of the results you want to

see, not in terms of what you will do.

4. Advocacy Objectives should be Specic, Measurable,Achievable, Realistic and Time-bound (SMART):10

Specic

Say what you mean in the clearest terms possible. Avoid jargon and vague wording, and beexact in the specic change you are seeking. For instance, terms such as empower or sensitizeare not precise and open to interpretation.

Measurable

Be as exact as possible about who, what, where, when, and how.

Achievable

The clearer you are about who, what, where, when, and how, the more achievable yourobjectives will be. Objectives should be achievable in the planned time frame and reectthe limits of your resources.

Realistic

Try to be as realistic as possible when you decide on your objectives, and take into account

the limits of available time, funding, and stafng. The more information you have about

your political context, target, and issue, the more realistic you can be.

Time-bound

Objectives should include a clear time frame within which change should be achieved.

Advocacy GoalDescribes your vision

and what you wantto accomplish overthe long-term.

Advocacy ObjectiveDescribes the smaller,more specic policy

changes that youwant to accomplish.

Objectives shouldclearly state whatit is

you want to change,whowill make that

change, by how much,by when, and should

be SMART.

Specic

Measurable

Achievable

Realistic

Time-bound

10VeneKlasen, Lisa; Miller, Valerie. 2007. A new weave of power, people and politics: The action guide for advocacy and citizen

participation. Warwickshire, UK: Practical Action Publishers.


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Example Advocacy Goal and ObjectivesIn this example, an organization in Uganda identied the problem of a weak health workforce

in their country. They further identied some of the many causes of this problem to be a lack of

country-wide HRH plans and the lack of a regulatory function and HRIS to monitor and regulate

the heath workforce. As a result, they decided to focus on two solutions and advocacy issuesto

inuence the establishment of (1) national HRH plans and (2) mechanisms to monitor and regulatethe health workforce.

After assessing that their organization was well placed to work on both of these issues, they created

their advocacy goal, describing their vision and what they wanted to accomplish in the long-term

and two SMART advocacy objectivesto articulate the specic policy changes they wanted to

achieve. They made sure that their objectives clearly stated whatthey wanted to change, who

would make that change, and by when.

Advocacy Goal:

Strengthen Ugandas health workforce by supporting policies to produce adequately trained,

equipped, and supported health workers.

Advocacy Objectives:

The Ministry of Health develops costed HRH plans that integrate the health workforce into

strategic health plans by 2012.

The Ministry of Health establishes subnational regulatory functions of the health professional

councils and the use of HRIS data and tools to strengthen the monitoring and regulation of its

health workforce by 2012.


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Case Story: National Orientation Practice for Newly Recruited Health

Workers in Tanzania (Benjamin William Mkapa HIV/AIDS Foundation)

Background and Context:Inadequate stafng of health workers is one of the main impedimentsof health sector performance in Tanzania, with a 72% shortage in the health workforce (Ministry

of Health and Social Welfare 2006).11Orientation of new public service employees in Tanzaniais mandatory. The formulation of the Public Service Management Strategy for Public Service in1998, and Act number 8 of 2002 recognizes the importance of orientation for newly recruited staff.However, a study conducted by Benjamin William Mkapa HIV/AIDS Foundation (BMAF) revealedthat orientation for health workers does not often take place and, if it does, it is only partiallyconducted. Furthermore, they found that there was no guide or package to deliver consistentorientations. However, BMAF understood that orientation of newly recruited staff promotesretention, a key factor in ensuring a stable health workforce.

Advocacy Goal and Objectives

Advocacy Goal:Ensure better health outcomes in Tanzania by creating a more stable healthworkforce.

Advocacy Objective: The Ministry of Health and Social Welfare (MoHSW) adopts and implementsby 2013 a national on-job orientation package to be used within Local Government Authorities inorder to promote effective staff settlement, ethical conduct, performance excellence, and staffmotivation.

Process: In 2010, BMAF developed an orientation package, with the review and inputs of severalstakeholders, including: Prime Ministers OfceRegional Administration and Local Government,

MoHSW, the Tanzania Public Service College, the Local Government Training Institute, the LocalGovernment Authorities, and District Hospitals of Njombe, Tandahimba, and Newala. The reviewalso gathered some inputs from independent human resources consultants. BMAF also worked withIntraHealth to compile the inputs from various stakeholders and incorporated them into the designof the Orientation Package.

To build local evidence with the orientation package, BMAF conducted knowledge-sharing forumswhere 54 Local Government Authorities exchanged ideas about how the orientation packagecould improve the retention of health workers. This evidence was compiled into a document thatwas shared at a policy table discussion with key policy-makers in September 2012. As a result, theMoHSW made a resolutions to work with the Presidents OfcePublic Service Management to

adopt and enforce the new Orientation Package through existing structures.

The advocates kept a consistent message throughout their advocacy, emphasizing that the adop-tion and implementation of the Orientation Package would add unique and practical value to theexisting initiatives on managing, retaining, and making productive human resources for health bycreating a conducive environment before, during, and after reporting to the workstation.

Outcomes:The National Orientation Package for Newly Recruited Health Workers in the Health

sector at the Local Government Authorities was then piloted by BMAF in collaboration withIntraHealth within the 54 districts. The monitoring and evaluation data of the pilot programsshowed that it contributed to the retention of health workers, which improved from an average of75% in 2010/11 to 91% in 2011/1212. Following the pilot, the Orientation Package was endorsed bythe MoHSW in 2013 and was disseminated to all Local Government Authorities in Tanzania for use.

Lessons Learned:It is important to involve the government and other stakeholders from the onsetof development of any policy document to ensure their buy-in and ownership from the beginning.

112013. Human Resources for Health Strategic Plan 2008-2013.Genva, Switzerland: Global Social Service Workforce Alliance. Geneva, Switzer-

land. http://www.socialserviceworkforce.org/resources/human-resource-health-strategic-plan-2008-2013 (accessed December 4, 2014)12Macias, Jennifer 2012. BMAF-Three years Performance report: 2011 June - 2014 June. IntraHealth International. Chapel Hill, North Carolina

http://pdf.usaid.gov/pdf_docs/PA00JZGP.pdf (accessed December 4, 2014)


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Chapter 6: Build PartnershipsThe Importance of Engaging OthersAt some point early in your advocacy planning, you will

want to start thinking about who else you should bring to

the table to be part of both the planning and the actions.This is important in building support for your advocacy

work and engaging other resources and skills. Building

partnerships may be an ongoing process throughout your

advocacy. You may invite some organizations and/or

individuals to be part of the development of the goal and

objectives for the advocacy work. Once the objectives

are set, you may realize that there are additional allies that

you would like to work with.

As you consider what partners to work with, it will be

important to:

Get to know/consult with other stakeholders and create partnerships: Set up networking meetings

with a variety of groups working on your issue or similar issues to see what they do, what has been

successful for them, and how you might work together. This can result in information sharing, invita-

tions to events, brainstorms, etc. that can help your advocacy work.

Identify and establish a presence in existing networks: Join existing networks that relate to your

advocacy issue and be part of their work and their collaboration. For instance, many countries

have AIDS coordinating bodies, NGO councils, and human rights networks. Identify relevant exist-

ing networks and gure out if it might make sense to collaborate or support one anothers work.

One example of an existing network is the HRH technical working groups that exist in many

countries. In Uganda, for example, the HRH Technical Working Group includes stakeholders fromvarious sectors, including NGOs, local nonprots, international organizations, and development

partners, and government representatives from the ministries of health and/or nance. The HRH

technical working group directly advocates to the Ministry of Health by providing strong techni-

cal guidance on how to create stronger health workforce policies. They played an active role in

helping to shape the political commitment to strengthening the health workforce that Ugandas

government made at the 3rd Global Forum for Human Resources for Health in November 2013 in

Recife, Brazil.

Build new partnerships: If groups coming together believe they have long-term interest in working

together, you may want to formalize your coalition and actually create a new organization or

formal network. For instance, AIDS and health rights groups in Kenya have come together to form

the United Civil Society Coalition on AIDS, TB and Malariawhich itself is made up of a variety ofcoalitions of PLWA groups, health workers, NGOs and activists. This network creates an opportunity

for all civil society to come together on issues around the Global Fund in Kenya, among others.

This is a major step, and not one to be entered into immediately.

There are many different forms of collaboration, and partnerships may be formal or informal, tempo-

rary or permanent. It is important to determine what kind of partnership makes the most sense for

your advocacy strategy and to be deliberate about whom you partner with and the type of collab-

oration that makes sense. The Partnership Mapping Tool will help you think through possible partner-

ships. The following provides a few examples of different types of partnerships:

Kenyan health professional students during the2007 AIDS Week of Action.


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Different Types of Partnerships13

Type Characteristics

Network Networks are often informal or with a limited structure and emphasis is mostly onthe exchange of information and less on joint work.

Coalition Coalitions usually have a more formalized structure and involve joint work, often amongfairly diverse civil society organizations around a single event, issue, or campaign.The different organizations divide the tasks in the most appropriate manner.

Alliance In alliances, trusted partners have long-term agreement on common ideals.Strategies and plans may be jointly developed and implemented.

Mobilizing the public may also be an important avenue for inuencing policy decisions, since policy-

makers often respond when there is great public support for an issue. Mobilizing people in your

community to be involved in your advocacy work is also critical in making change sustainable

and responsive to the needs of people directly affected by the problem. Part of your strategy may

include building the capacity of and empowering certain constituencies to be more involved in or

take on more leadership for your advocacy work.

Benets and Challenges of Working with OthersThere are both benets and challenges to working with others, particularly in a more formal coali-

tion, to achieve your advocacy objectives. A coalition may help you win what you would not be

able to win alone by increasing the impact of an individual organizations efforts, as well as increase

resources. On the other hand, working in a coalition means that you may have to compromise on

some of the issues that you take on in order to build consensus. Keep the needs of your advocacy

initiative paramount. The following are some examples of the benets and challenges of working

in a coalition.

Unied voice:Having a unied voice

can be stronger and more powerful.

Increases the resource base:Often

organizations may have complementary

skills sets, expertise, and resources and

can ll each others gaps.

Avoids competition and duplication

Wider audience base:Organizationsmay have different constituencies,

which can widen the audience and

support for the advocacy work.

Turf issues:Organizations and individuals may

be sensitive about sharing their work.

Domination by one group or organization: When

starting a coalition, it is important to create a partici-

patory atmosphere and encourage everyone to give

their ideas and time so no one group dominates.

Failure to provide and create leadership within

the coalition: Coalitions demand a very special kind

of collaborative leadership, which can harness thestrength of everyone involved.

Time consuming:Coordination among coalition

members can be time-consuming.

Difculty coming to agreement:It can sometimes

be hard to agree on goals and may require some

compromises.

Benets Challenges

13Gosling, Louisa and Cohen, David. 2011. Advocacy matters: Helping children change their world :An International Save the Children

Alliance guide to advocacy.London, UK: The International Save the Children Alliance. http://www.unicef.org/adolescence/cypguide/les/

Advocacy_Matters_Participants_Manual.pdf (accessed December 3, 2014)


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Tips for Developing Coalitions

1. Choose unifying issues. The most effective coalitions come together around a common issue.

Make sure the development of group goals is a joint process.

2. Understand and respect each groups self-interest. There must be a balance between the goals

and needs of the coalition and of the individual organizations.

3. Respect each groups internal process. It is important to understand and respect the differences

among groups. These differences are often apparent in processes or chains of command for

decision-making. Make a commitment to learning about the unique values, history, interests,

structure, and agenda of the other groups and organizations.

4. Acknowledge and use the diversity of the group. Every group has something similar and different

to offer, and every groups ideas and inuence can help the coalition succeed. Not everyone

will always agree with everything the coalition does or wants to do. Make sure to take every-

ones opinion and restraints into account and to use diversity as a spur to discussion, rather than a

source of division.

5. Communicate openly and freely with everyone. Ensure that the lines of communication within

the coalition and among the coalition, the media, and the community are open. Open commu-

nication will ensure that no one feels left out and that everyone has the information necessary to

make coalition efforts successful.

6. Structure decision-making carefully. Finding consensus is very important when making decisions

as a coalition. Every group must listen to each other, debate, and discuss until they can nd

common ground.

7. Distribute credit fairly. Recognize that contributions vary. Each organization will have something

different to offer. Each one is important, so be sure to acknowledge them all, whether they

contribute volunteers, meeting space, funding, copying, publicity, passing resolutions, orother resources.

8. Be inclusive and participatory. Work at making sure everyone feels welcome. Try to involve every-

one in the coalition in generating vision and mission statements, planning, and making major

decisions. The more people feel ownership of the collation itself, the harder they will work to

achieve its goals.

9. Give and take. It is important to build on existing relationships and connections with other organi-

zations. Dont just ask for or expect support, be prepared to give it.

10. Develop a common strategy. The strength of a coalition is in its unity. Work together with other

organizations to develop a strategy that makes sense for everyone. The tactics you choose shouldbe ones that all the organizations can endorse. If not, the tactics should be taken by individual

organizations independent of the coalition.

11. Be strategic. Building coalitions in and of themselves requires a good strategy. Which organiza-

tions you ask, who asks them, and in which order are all questions to gure out. Are there organi-

zations that have particular skills or perspectives that the coalition would benet from? Or particu-

lar constituencies or relationships that would strengthen the coalition?


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Case Story: The NGO Code of Conduct for Health Systems

Strengthening (Health Alliance International)

Background and Context:The NGO Code of Conduct for Health Systems Strengthening developed

as a response to growing awareness of the harm that international NGOs were inicting on host

countries in which they worked. This harm, though sometimes unintentional, includes NGO hiringpractices which distort local health worker salary scales (by offering up to ten times what local minis-

tries of health were offering), poaching the highest qualied health workers from public sector health

systems, and creating a huge management burden for host governments to coordinate myriads

of donor-funded projects. As a result, there was a desire to provide a guide for international NGOs,

donors, and ministries of health to limit the harm that current international aid funding schemes can

inict and which could be used to commit to best practices and for advocacy.

Advocacy Goal and Objectives:

Advocacy Goal:Improve country-level health systems by ensuring that international NGOs and

donor policies are committed to best practices surrounding hiring, compensation policies, capaci-

ty-building, and support for public sector systems building.

Advocacy Objectives: 150 international NGOs sign on to the NGO Code of Conduct by 2016.

Ten major donors and ve ministries of health sign on to support the NGO Code of Conduct and

make adherence to the code a condition of funding or allowing an international NGO to operate

within a host country by 2016.

Process: The NGO Code of Conduct is truly a collaborative project. It was born when a consortium

of NGOs, including Health Alliance International (HAI), ActionAid, Partners in Health, Health GAP,

Oxfam International, and others met up at a health conference to brainstorm advocacy initiatives

to address issues related to bad NGO practices. Over the course of several months of teleconfer-

ences, email exchanges, and draft revisions, the consortium nalized the draft code and published itonline on the NGO Code of Conduct website. In 2014, the drafters reconvened to refocus the target

audience to include the donor community and ministries of health. The original drafters engaged

in conference calls and meetings at international conferences to map donor and ministry of health

contact networks. A major goal of the code is to raise awareness and outreach to organizations and

donors, so the drafters and especially HAI are focusing on presenting it in journals, at international

forums, and other media outlets.

Outcomes: To date, approximately 60 international NGOs and one donor has signed on to the

NGO Code of Conduct. The code was featured on a radio interview (Against the Grain), a podcast

(Humanosphere) and a comment was published in the Lancet in August 2014. The code has been

presented at two international conferences in 2014. Progress towards the objectives is primarily

due to renewed outreach and a refresh of publicity materials (including the website) undertaken

in early 2014.

Lessons Learned:Specic lessons learned from this work include the importance of strong, sustained

collaborations (including face-to-face meetings, regular emails, and conference calls) among like-

minded groups to keep momentum for advocacy efforts going. Strong network mapping has also

been critical to growing support for this effort.


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Tool: Partnership MappingPlease list the potential partners that you are already working with or are planning to work with to

carry out your advocacy strategy.

Partnerships (Local, National, Regional or International)

Name Goal of Partners Position on Type of Partnership and

Partnership Advocacy Issue Tactics for Collaboration

1.

2.

3.

4.

5.

6.


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Photo courtesy of Jhpiego


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Advocacy Toolkit

Chapter 7: Get the FactsAdvocacy must be grounded in evidence about the problem you are focusing on and the feasibility

and value of your proposed solution. You will also need to collect information throughout the

advocacy planning cycle in order to understand the policy process, your targets, and to monitor,

evaluate and learn from your advocacy work.

Why Gather Evidence?Three important reasons to gather evidence include: to ensure an accurate and full understanding

of the change you are trying to inuence; to help persuadeothers to make or support that change;

and to monitor, evaluate, and learnfrom your advocacy work.

1. Understanding and Analysis

Your advocacy work needs to be grounded in solid evidence and policy analysis to fully understand:

The contextof HRH globally and in your country (for more information, see Chapter 3:

Understanding the Context)

The problem, the problems scale and severity, and the impact on peoples lives

The feasibility of possible solutionsincluding their costs and effectiveness, examples of what works,

innovations that can be tested, and the likely impact of change

If you are accurately representingneeds, priorities, and interests of your constituencies

The policy and decision-making process, who is responsible to make the change you seek to

inuence, and what their interests are (for more information, see Chapter 8: Understand the Policy

Process and Chapter 9: Identify and Analyze Targets).

2. Persuasion

The evidence you gather will be critical for convincing the key decision-makers and others why the

change you are advocating for is important and will enhance your credibility and professionalism. Fo

example, it is one thing to say that the distribution of health workers is a problem. It is far more power-

ful to say that a certain district has ten times fewer health workers per capita than another district. It

is one thing to say that more health workers are needed. It is far more powerful to point out that your

country has only one-third the number of health workers that the World Health Organization considers

a minimum requirement.

When gathering or generating evidence it will be important to consider how to:

Tailor your evidence to the interests of your targets: It will be important to understand who the

key decision-makers are and what kind of evidence will be persuasive to them (for more informa-

tion, see Chapter 9: Identify and Analyze Targets and Chapter 10: Develop and Tailor Messages).

You may tailor the kind of evidence you collect to t their interests. For instance, are the mainpriorities of the key decision-maker(s) dealing with economic growth? National security? Social

equality? Depending on their priorities and interests, different kinds of evidence will be needed

to convince them.

Demonstrate support for change:It may also be important to collect evidence about current

support for change from those affected by the problem, those with power, and other interested

stakeholders.

3. Monitoring, Evaluation, and Learning

You will also be gathering evidence along the way to monitor, evaluate, and learn from your

advocacy work (this will be discussed more fully in Chapter 13: Monitor, Evaluate, and Learn).


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Information GatheringIn order to gather the information you need to begin your advocacy work, you will want to consider

whatinformation you need, whereyou can nd that information, and whowill help you gather that

information. The Mapping Evidence Tool will help you think through:

What information do you need?

It is useful to think of this in terms of what questions you need

answering. Where are the gaps in your knowledge? What are all

the policies relevant to your issue? What demographic statistics

will help make your case? Breaking down the required information

into parts will help you plan to research it, particularly helping you

to distinguish between information that will be easy to obtain and

information that requires more effort.

Where can you nd the information?

Partners and Stakeholders:Some of your partners and stake-

holders might have information

that you need, such as:

o Relevant Ministries (e.g., Ministry of Health or Ministry of Finance)

This information may be gathered through meetings or obtaining documents from ministry ofcials.

You may also nd needed information in ofcial policies, strategies, and reviews. The availability of

public documents will vary by country, with a growing amount of this information also publicly avail-

able through the Internet.

o Other NGOs, CBOs, and Coalition Partners

It will be important to leverage the varied strengths of your partners. For example, an NGO that works

on budgets might have information on health spending, and an NGO that works on HIV/AIDS might

know whether money from the US global HIV/AIDS program

HWAI Advocacy Toolkit

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