# A review of the role of civil society in advocacy and lobbying for enforcement of health policy in Kenya

# Examen du rôle de la société civile dans le plaidoyer et le lobbying en faveur de l'application de la politique de santé au Kenya

Patrick Abuya Omungo

Centre for Health and Social Research. PO Box 205-00200 Nairobi, Kenya
+254 0722 594613 or 0731 343732

patrickomungo@gmail.com

## Abstract

Advocacy and lobbying are more taking an ever more central place in health agentes of African countries. It is impossible to have a conversation about public policy these days without someone mentioning 'civil society'. Unfortunately, clarity and rigor are conspicuously absent within civil society. Advocacy and lobbying for enforcement of health policy is called for because of civil society's tendency to concentrate on commercial interests rather than health equity. A States' first duty towards citizens is to respect the right to health by refraining from adopting laws or measures that directly impinge on people's health.

There is evidence from the literature of civil society organization (CSO) intervention in support of primary health care, equity in health and state health services. Our desk review yields 38 online documents. Information obtained from the desk review is analyzed vis a vis interviews from visits to three selected key informants who are a government official involved in health policy formulation at the ministry of health and two civil society organizations officials from the health NGO network. Key themes emerging from our consultations are discussed during the 27th annual scientific conference hosted by the Tanzania Public health association at St. Gasper conference centre, Dodoma, Tanzania 2-6th November 2009. From a PowerPoint "oral" presentation participant's queries are input.

Based on our interpolation of the civil society consensus articulated at the Tanzania Conference we establish that the centrality of a right to health framework is an important basis for policy. Our interviews establish that countries should ensure that public health principles and priorities are clear and legally binding across countries should have a clear coordinating mechanism on issues of trade and health that involve government, particularly health ministries and civil society. Civil society needs to disseminate health and trade information in assessable ways. Challenges faced by lobbyists are foreign funding for capacity building initiatives and availability of technical expertise to inform the policy making process adequately.

**Key Words:** Advocacy, representation, lobbying, HENNET, policy
Résumé

Le plaidoyer et le lobbying prennent de plus en plus une place importante dans les programmes de santé des pays africains. Il est devenu quasiment impossible de tenir une conversation sur la politique publique sans que quelqu'un ne parle de "société civile". Malheureusement, il manque de la clarté et de la rigueur dans la notion de société civile. Le plaidoyer et le lobbying dans le renforcement des politiques de santé est nécessaire à cause de la tendance de la société civile à se concentrer sur les intérêts commerciaux plutôt que l'éthique en santé. Le premier devoir des États envers les citoyens, est de respecter le droit à la santé en s'abstenant d'adopter des lois ou des mesures qui pourraient toucher directement la santé des individus.

IL existe des preuves de la littérature des organisations de la société civile (OSC) des interventions en faveur des soins de santé primaires, l'équité dans la santé et les services de santé d'état. Notre étude théorique a fait la revue de 38 documents en ligne. Les informations obtenues de la revue ont été analyses et ont servi à faire des entretiens individuels avec trois informateurs-clés que sont un fonctionnaire du gouvernement impliqué dans la formulation de politiques au niveau du ministère de la santé, et deux membres des organisations de la société civile et du réseau des ONG de santé. Les principaux thèmes émergents de nos entretiens ont été discutés lors de la 27ème conférence scientifique annuelle de l'association tanzanienne de santé publique tenue du 2-6 Novembre 2009 au centre de conférence St Gasper à Dodoma en Tanzanie. Après une présentation "orale" par power point, les contributions des participants ont été prises en compte.

Sur la base de notre interpellation au consensus de la société civile définie à la Conférence de Tanzanie, nous montrons que la centralité du droit à un cadre de santé est une base importante pour la politique. Nos entretiens permettent d'établir que les pays devraient s'assurer que les principes et les priorités de la santé publique sont clairs et juridiquement contraignantes\ les pays devraient avoir un mécanisme clair de coordination sur les questions du commerce et de la santé qui impliquent le gouvernement, en particulier les ministères de la santé et la société civile. La société civile a besoin de diffuser l'information sanitaire et commerciale de façon évaluable. Les difficultés rencontrées par les lobbyistes sont les fonds étrangers pour des initiatives de renforcement des capacités et la disponibilité des compétences techniques afin d'informer le processus décisionnel de manière adéquate.

Mots clés: Plaidoyer, Représentation, Lobbying, HENNET, Politique

Introduction

Our interpretation of consensus emerging at the 27th scientific conference organized by the Tanzania public health association (TPHA) is that Advocacy, civil society and lobbying are central to health agendas of African countries. It is

impossible to have a conversation about politics or public policy these days without someone mentioning the magic words civil society. Unfortunately, clarity and rigor are conspicuously absent in civil society debate. Advocacy and lobbying for enforcement of health policy is called for because of a tendency to
concentrate on commercial interests rather than health equity. While numerous articles are written on policy issues, there is less on the policy processes and very little published work that analyses the relationship between processes actors and inputs in relation to specific policy outcomes.

Civil society means fundamentally reducing the role of politics in society by expanding free markets and individual liberty. Civil society is a special product of the Nation or State and capitalism. The works of civil society are a universal expression of the collective life of individuals at work in all countries and stages of development but expressed in different ways according to history and context. Recognizing that civil society does indeed mean different things to different people is one of the keys to moving forward because it moves us beyond false universals and entrenched thinking. Realizing these ideals like political equality or peaceful coexistence requires action across many different institutions, not just voluntary associations. Since the 2002 general elections in Kenya, civil society organizations have grown substantially in number and influence. But, are these groups at a point now where they play a determining role, alongside government, in public policy-making?

## Literature review

Based on a systematic attempt to generate information on the role of CSOs in the health sub sector with regard to participation in policy making, our literature search reveals that throughout the decade over 100 CSOs are established annually (Newton K., 2000). Our government's long-term health policy

and development frameworks strongly emphasize their role and centrality of collaborative cross sectoral partnerships. Republic of Kenya (1994, 1997a). In recent years, CSOs have become more prominent, more visible and more diverse, with a growth in their number, type and budget turnover.

Civil society organizations are variously situated within and among public policy, academia, and the community and seem well placed to negotiate matters of public concern. However, it is not always clear what authority CSOs have to do so and whose interests they represent. From our evaluation, what is clear is that CSOs ought to collaborate with the government to

* Identify what the needs of the people are: Advocacy activities need to identify the spokespersons for and against the change proposed and engage them to alert the government to any adverse effects of the proposed change.

* Set the agenda in establishing policy objectives, goals of the advocacy plan, principles and key messages of the plan.

* Adopt policy through platforms and processes where goals will be achieved.

* Monitor and evaluate the policy.

Civil Society in Kenya is a force for more human centered development. It is the responsibility of government to provide for its citizens, civil society should only play a complementary role. Our respondents agree that the practice of advocacy is still relatively young. Situations exist where interaction between the government and Civil society organizations may occur but fail to translate to policy; also, the government of Kenya may approach civil soci-
ety organizations only to rubberstamp
what it has already decided on, not any
form of consultation, Kaulem J (2007).

Poor information flow within Gov-
ernment of Kenya itself and lack of
internal synergies between government
departments constantly means that dif-
ferent government departments and
civil society organizations would take
different positions on the same issue
making it very confusing for CSOs
involved in collaborations. CSO Net-
works have enough capacity to compel
the government to hear their voices, to
show the government that they will not
accept anything that comes their way.
To articulate to the government that
they will not find an easy way out of the
dilemma of finance and maintenance of
our national services. Required to
achieve this is clarity, greater clarity
about the potential and springboard of
civil society (The third leg) and ability of
civil society to influence policy. Moreo-
ver, we need to be conscious that we
are seeking not only changes in written
policy but also above all, changes in pol-
icy as expressed on how decisions are
actually made and actions taken.

Pan African social policy frame-
works will be more successful if
anchored in clear national social devel-
opment policies. Our government's fail-
ure to develop comprehensive social
development policies is a reflection of
absence of such policies from the sys-
tems they had inherited. What we see
today in most of our African countries
are pieces of social policy frameworks
in health, education, environment e.t.c.
Through civil society, these pieces are
anchored into clear national social
development policies.

My study is located in the wider

theoretical discourses of the new social
policy paradigm and the “paradigm of
partnership” The participation dis-
course is also of particular importance
given the rationale it gave to the Health
for All HFA/ PHC preventive/promotive
health care movement, and more
recently also to the participation of pri-
vate players in specialized health care.
Mullard and Spicker (198), Singh P. K
(2002). There is evidence from the lit-
erature of CSO intervention at interna-
tional level in support of primary
healthcare, equity in health and state
health services. CSOs have lobbied for
the rights of communities with specific
health needs, including consumer lob-
bies, people with disability, people living
with HIV Aids.

Data and methods

The ideas presented in this paper build
on discussions by a scientific conference
and are enriched by further interaction
with stakeholders. Between 2nd and 6th
November 2000, Tanzania public health
association hosted the 27th Annual Sci-
entific conference at St. Gasper confer-
ence centre Dodoma Tanzania. The
oral presentation at the Tanzania public
health association (TPHA) conference
was based on literature review, and dis-
cussion with civil society organizations,
policy makers, implementers and other
stakeholders. Prior to the conference,
literature reviewed include 38 online
documents consisting of papers, institu-
tional reports, technical notes or other
documents produced and published by
governmental agencies supplemented
by hand-searches of bibliographies of
retrieved articles and tables of contents
of key journals. Information retrieved
from the desk review is analyzed vis a
vis interviews with three key informants, one government official at the ministry of health and two civil society organizations officials from the Health NGO network HENNET. Retrieved articles draw insight to policy processes and CSO roles. At the conference, we conferred with participants during oral presentation of an IBM compatible electronic copy. Participants of the TPHA conference agree that pluralism and difference in perspective coupled with good management of participation and debate can contribute to healthy debate in society and to more informed policy making. After the Tanzania public health association conference, we maintain personal communication with the TPHA conference secretariat to shape contents of my presentation. Reactions echoed by the conference audience have a broad relevance to health systems development in advanced welfare states and developing countries in general and in particular for the understanding of complexities surrounding CSOs in this sub sector of social policy in Kenya.

## Results

For this review, we refer to departments for international development's (DFIDs) definition of civil society. Civil society is the multitude of association's movements and groups where citizens organize to pursue shared objectives and common interest. Civil society consists of, an independent Media (Print and electronic). Media serve as an important information source for the community at large and can be influential in shaping public opinion at all levels. It is essential for members of the media to have accurate and current information

on the work of local institutions. Media and journalists can disseminate accurate information and may assist with specific recruitment activities, provided they are well-briefed, general community outreach and education.

Voluntary social service or development organizations first reveal aspects of civil society as associational life, as genes of the good society, microclimates for developing values like tolerance and cooperation and the skills required for living a democratic life. Second they reveal civil society as the good society: It sets the contributions of voluntary associations in the proper context and guards against the tendency to privilege one part of society over others on ideological grounds, voluntary organizations over states for example. Third they reveal civil society as the public sphere with development of shared interests, the ability to bring those who are different to work together for effective governance, practical problem solving and peaceful resolution of our differences.

Other examples are Women's organizations/Federations/Development organizations, groups and research centers, Trade and peasant unions, federations, Consumer groups and organizations, Academic and research institutions. Community members often look to academic and religious leaders for advice on important decisions, including joining a vaccine trial, Ethnic, caste, Religious, professional bodies and associations. Indigenous peoples organizations. It is important to include traditional healers (Where they exist) in defining civil society since they serve an important role in giving care and advice.
Civil society provides norms and networks of trust that can improve the efficiency of society by facilitating coordinated public action. Within the global policy process, we found CSOs to strengthen public interest lobbies and balance corporate and market pressures making what is reported as valuable and sometimes essential contribution to successful policy outcomes. Civil society organizations (CSOs) and networks are important players in policy formulation making process. Through CSO networks, state society relations are improved. A number of studies show a shift from CSOs as outsiders raising policy issues to informed insiders, involved in the policy process. A strong civil society contributes to an effective state that can protect people's human rights, support economic growth, tackle corruption, and provide security and basic services like education and health care. In many cases, civil society organizations offer the only opportunity for poor people to engage with the state. Participation of civil society organizations in policymaking is beneficial for all players within the policy processes through reducing conflict, facilitating communication and bringing new expertise into policy processes (Weiss 1997; Koh 2000, Gellert 1996, Coulby 2001).

Promotion of the responsible exercise of these rights for all people is the fundamental basis for government and community supported policies and programs. By formulating health policy, we identify who are the main initiators, who bears the costs and who are the main beneficiaries.

These consist of:

* A purposive course of action followed by an actor or set of actors (Anderson 1984)

* Agendas

* Creating formal spaces

* Official statements/Documents

* Passing Laws and enforcing existing laws

* Patterns of spending

* Implementation processes

* Activities on the ground

A national health policy is a formal government statement, which defines priorities and parameters for action in response to health needs, available resources and other political pressures in close consultation with stakeholders including communities. The objective of policy is to develop and formulate strategies that will assist in the sustainable reduction of the disease burden among the population through improved standards.

In 2004, the Ministry of health produced Kenyas Health Policy Framework KHPF 1994-2010, which is the governments blue print for future development in the health sector today. The aim of the policy framework is to ensure that the health status of Kenyan population is improved. Current policy objectives of the Ministry of Health (MOH) in Kenya lay increasing emphasis on preventive/promotive health while encouraging the participation of the non-governmental organizations, private sectors, communities, households and individuals (Republic of Kenya 1998b). Since 2005, Health civil society organizations have come with a common mission "to stimulate linkages and strategic partnerships among health Non governmental organizations, government and private sector in order to enhance their responses towards health needs of Kenyans "Health NGOS Network (HENNET). As one of the Key stakeholders in the health sector, HENNET has been in the forefront in pushing for the development of a public private partnership policy in Kenya.

A series of countrywide forums in
policy development and lobbying activi-
ties resulted in the adoption by cabinet
and parliament of sessional paper
number 4 of Ixxx, which became the
country's national HIV AIDS policy.
During consultation with civil society
organizations and other stakeholders,
emphasis has been placed on availability
of accurate and up to date information
documented by government and a pub-
lic well enlightened on how they can
participate. To address all the issues
concerning the health sector, the litera-
ture reviewed insinuate that the envis-
aged policy addresses five areas;
Information-education and communica-
tion, legal framework, Institutional
framework, Technology and resource
mobilization. Through a review of exist-
ing legislation/policies Civil society
organizations aim to identify inconsist-
encies, contradictions, inadequacies
with enforcement, to examine existing
laws and policies with a view to propos-
ing policy statements that broadly
address the five areas mentioned above
and specifically put privatization, stand-
ardization, gender issues and disaster
management as a key agenda. Such a
review also examines responsibility and
legal mandate of key sector actors
related to health policy.

Though civil society organizations
have been involved in policy implemen-
tation of the first health sector strategic
plan Ixxx-2004, objectives set out in
the plan are far from accomplished.
Despite NHSSP I emphasis on the need
to prioritize primary health care, alloca-
tion of health resources today however
is skewed in favour of the tertiary and
secondary facilities that offer curative
services. The NHSSP II Launched in
2005 strategy is to strengthen primary

health care services in order to facilitate
low cost and assesseble services in rural
areas (Republic of Kenya 2005). Health
civil society organizations need to
broaden and institutionalize relation-
ships with Ministry of health such that
they are not dependent on one or two
individuals. The new plan (NHSSP II) is
said to be practically operational and
based on consensus among policy mak-
ers than the NHSSP I was.

Civil society in lobbying for enforce-
ment of health policy in Kenya sets its
agenda through household level
approaches, community leaders and
others, Markets and cooperatives, Gov-
ernment programs. Its agenda target
the following barriers: Need, Percep-
tion of need, Permission, Ability and
Availability. At the household level civil
society, address gender bias, and barri-
ers to communication. With markets,
Credit savings groups/cooperatives civil
society agenda include drug prices,
generic rather than brand name drugs,
quality versus cost. With government
programs civil society forum addresses
raising morale, sensitivity, accountabil-
ity, monitoring and evaluation, Involve-
ment in planning, implementing
programs.

Market level approaches to influ-
ence policy should ensure we build
domestic markets and revive demand.
Civil society organizations are con-
cerned with revival of demand, which
can be the basis for domestic produc-
tion of savings, domestic mobilization of
investment tax revenue and so on. One
way is to rollback the deregulation and
liberalization of the financial sector and
to have a rethink of policy based inter-
ventions. For example banks need to be
told you will spend X Percentage on
Health investment. Business Daily (Fri-
day July 10 2007)

Discussion

Boundaries of Civil society organiza-
tions the state and the markets are
often blurred because these groups are
constantly interacting and negotiating
around common issues. Approaches
adopted by civil society are household
level approaches, with community lead-
ers and others, with markets and coop-
eratives and with government
programs. Broadly CSOs are mandated
to target barriers of Need, perception
of need, permission ability and availabil-
ity of health policy. Civil society, organ-
ized interest groups and public sector
are a tremendous force in terms of
push and watch. In my view, that's not
enough. What is required is a funda-
mental shift, boldness and audacity. This
will not come from the elites who have
benefited and profited from the state of
things. They will tinker, they will make
sure they pass on the burden to some-
one else; it's our job to ensure that
does not happen.

There should be targeted policy
prescriptions of which the precondition
should be public participation where
needs of different communities and sec-
tors are debated and harmonized so
that tradeoffs can be seen to benefit all
working people. Batliwala (197)
....."state must create a kind of suction
effect which accelerates the momen-
tum of and absorbs the thrust for
change emerging from the communi-
ties". We must therefore recognize sev-
eral conflicting forces which operate
within civil society. Those both formally
and substantially committed to activities
of civil society, those partially commit-

ted or unclear, those completely
opposed to this agenda. In between is a
mass of ordinary citizens whose sup-
port is sought to be mobilized by both
the opposing sets of actors. Civil society
organizations inform, influence or chal-
lenge the state a role often referred to
as the demand side of governance.

The growth and increased pressure
from CSOs for greater access to policy
making have raised the profile of civil
society participation in policy develop-
ment. This is explored below in terms
of the areas of health policy that cur-
rently attract CSO attention, how civil
society organizations participate
through what processes, what inter-
ests are served in such policy influ-
ences.

Civil society in Kenya has made a
range of interventions both practical
and strategic. Building a supportive
environment: Building support at the
country level means raising levels of
awareness (consciousness) and educa-
tion so people are familiar with the
Idea, people have power to demand
more from government and politicians.
In country advocates and stakeholders
are also strong allies in increasing will-
ingness of community members to
learn more (through rigorous context
assessment) and consider volunteering.

Shaping in country policy and build-
ing advocacy: Community groups and
the media create an enabling environ-
ment by promoting policies and building
capacity to support rapid regulatory
review, sufficient community health
infrastructure and meaningful commu-
nity participation. To achieve this Civil
Society Organizations conduct inde-
pendent research and analysis of poli-
cies and their impact including impact of
Market forces. Advocacy and advisory work with both public and private bodies including the partially committed civil society organizations & informal contacts to avoid future policy inconsistency.

Linking with local, national and global information sources: At the local level, links have been developed between medical centers, ministries of health, universities, NGOs and others involved in Aids vaccine. Networks can be created between various audience groups. Suggestions have been made to set up an ombudsman where complaints by the citizens regarding the sector particularly relating to service delivery can be channeled. Further civil society organizations should invest in mechanisms for interministerial and intergovernmental communication including joint events and dialogue to ensure better coordination of trade and sustainable development.

Sharing information: Participating in local, national and international conferences (Sharing Knowledge) joining local HIV AIDS prevention and care networks and trial sites and publishing research findings in newsletters and on websites are good ways to share information. This entails exploring areas of common interest among members and facilitating partnerships and alliances between researchers, policy makers and communities. Through participating and dissemination information, policy processes are more publicly assessible.

Most of our governments do not have the requisite skills and capacity to effectively address social development issues. Our review suggests that effective partnerships among stakeholders, governments, development partners

and civil society organizations are imperative. Such partnerships go far to enhancing capacity, increasing coordinated avenues for policy development and accessing fund raising avenues by brokering relationships with the government inform of commissions. A capable state formulates and implements policy in a participatory effective inclusive manner. Rich and diverse contributions of CSOs to policy in Kenya has in the past been achieved through participatory planning policy and budget formulation, community trainings, providing service to those groups unreached by public service and to whom private services are affordable. Providing legal awareness, legal aid and initiating public interest, litigation, class action suits/test castes.

Ensuring transparency and accountability, is a politically sensitive issue for Civil Society organizations and government in Kenya: There is need to put in place, Careful financial audit, Human resource management policies and practices outside evaluation of activities and projects.

Mobilizing volunteers, Efficacy trials may require several thousand volunteers who are not infected with HIV and to recruit that many people, many more must be reached. Regular community outreach forums, workshops, exhibitions are required. Such CSO influence on policy through service roles has also been noted in the children's vaccine initiative (CVI) work on policy conflict between public-private sectors on vaccine policies.

Ensure geographical equity of health service delivery facilities, levels of care, human resources, supplies and logistics; Health systems strengthening,
quality partnerships. Strengthen nursing and midwifery services, blood safety oral health services, mental health and substance abuse prevention. Health care is a common good; CSOs should ensure that it is not commoditized. They monitor health and human rights issues such as patients' rights, women's and children's health rights, Reproductive health rights and occupational health risks.

Civil society organizations are dynamic. Each of their roles are interconnected but CSOs engage in any of the following activities: Influencing standard setting (Lobbying for legislation on transparency). Carrying out investigation (Monitoring and evaluating government programs through participatory expenditure tracking systems, Demanding answers from the state e.g. questioning state institutions about progress, parliamentary and public hearing, applying sanctions where the state is found to be lacking (Protests, Boycotts, strikes and negative publicity). They bring human resources, technical expertise and new knowledge to health and provide a powerful additional pressure for the recognition of public interest. Analysts point out how civil society participation in research and policy has led to the generation of new data sources, more sensitized and knowledgeable stakeholders, empowered advocacy groups, increased accountability and meaningful sustainable policy change. (Innes 1,8, Epstein 1,6, Khilnani 2001, Cornwall 2000)

While the state dominates the policy making process in Kenya, Civil society organizations play extremely important roles. Their contribution is not simply at agenda setting stages, by

lobbying government but in the actual development and implementation of health policy through networks (ICASO 1,7). The studies in this review point to CSO influence largely coming from the strength visibility and resource base of CSO coalitions supported by information access and exchange. HENNET is an outstanding best practice of a network that brings together health civil society organizations. HENNET stands for Health NGO network. HENNET is the only civil society organization network that covers the health sector in totality. Few countries have established such well functioning health networks and HENNET has inspired other countries to establish similar health networks in order to unite focus and strengthen coordination. HENNET has been instrumental in ensuring that health NGOs and FBOs are fully integrated and recognized in the health sector both in terms of policymaking coordination and actual provision of health services. HENNET illustrates CSOs policy influence; how external actors are able to interact with the policy process and affect policy positions, approaches and behaviours. This policy network notion emerging in Kenya, can be used as a tool for describing, exploring and understanding interconnections between actors and also as a tool by policy makers to plan for policy change. The network provides policy makers with evidence necessary to assess policy alternatives.

## Conclusion

Three observations are worth noting which suggest that in Kenya today, policy processes are no longer dominated and controlled by state actors. First
regards the formation of civil society organizations; Increasing number of CSOs are being established to work in HIV AIDs related programs without necessarily declaring their interest in or taking on Family Planning Programs as an add on to their activities. Second touches on integration, CSOs that were traditionally or primarily Family planning organizations are also increasingly turning their attention to integrating HIV AIDS into their Family planning programs. Specifically, relationship between government and CSO change overtime. Third, is that the extent of

CSO influence on policy is independent of government. CSO influence is not limited to national borders, but extends beyond. By getting the fundamentals right, assessing context, engaging policy makers, getting rigorous evidence, working with partners, communicating well, CSOs can overcome key internal obstacles. There are also growing concerns about the legitimacy of CSOs, particularly with regard to whose interests they represent and to whom and for what they are accountable as illustrated in the following verbatim.

<table><thead><tr><td>Catchphrase</td><td>Evidence from literature</td></tr></thead><tbody><tr><td>Civil society organizations are accepted by a wide range of stakeholders in policy including, government, parliaments and local authority bodies.</td><td>"My thinking is that CSOs should concentrate on advocacy and creation of demand for services rather than provision of services ... I would rather have the government improve its health services to meet that demand... (Marie stopes/Kenya). ................................. Country analysis of family planning and HIV AIDS: Kenya Colette Aloo Obunga Population and health consultant Nairobi March 2003 Policy.</td></tr><tr><td>Civil society organizations are important in setting sexual and reproductive health into the National health agenda.</td><td>"This may be the time when we need family planning the most as well as accurate and the right information including benefits of protection against diseases, the time to promote condom use is here and now" ................................. FPAK</td></tr><tr><td>Health policy formulation is an all-inclusive process. Ministry officials regularly consult Civil society officials on various policy issues.</td><td>The organization attended two national consultative meetings where there were hearings and informal contributions and then worked with the group of civil society organizations that represented the entire civil society sector in the process......... Actors reacted to already prepared views of the government instead of starting from scratch in preparing the document. On the other hand, he admits that the process opened up opportunities for future meaningful and effective participation" ................................. Africa budget watch interviewed sodnets Boniface Owinga</td></tr></tbody></table>
<table><tr><td>Civil society organizations have consistently participated in awareness creation.</td><td>In the wake of the December 2007 Post election violence, the health policy initiative also supported KETAM (A national activist movement that aims to advocate and lobby for increased access to treatment) and the United Civil society coalition against AIDS, Tuberculosis and Malaria (UCCATM) in carrying out a rapid assessment of the effects of the violence on PLHIV. The assessment focused on issues of policy, coordination and access to treatment. It found that the displaced people did not know where to access ARVs and OI medicines. The government used the information to make these medicines available for displaced individuals. The findings will also be used to help plan the country's response to future emergencies. USAID Health policy initiative' Demanding Access</td></tr><tr><td>Civil society participation in the policy process is dependent on funding sources.</td><td>As a result of POLICYs advocacy work in 2005, a budget line for FP/RH was included in the budget line for the first time. This made it possible for advocates trained by the health policy initiative to lobby for increased FP/ RH Funding. Sustaining policy change. Health policy initiative helps foster an enabling policy environment for reproductive health in Kenya.</td></tr><tr><td>Civil Society Organizations are yet to unearth their full potential in policy formulation in Kenya</td><td>You'll need to come up with a case study of how civil society organizations have participated in the policy making process. Dr. Muthoni Kariuki Program manager Jhpiego, St. Gasper Hotel and Conference Centre</td></tr><tr><td>Civil society organizations reveal a unity of purpose. They promote public consensus and local ownership.</td><td>Civil society organizations have no common definition of what advocacy is and also do not agree on the type of activities it covers. Paradoxically, however they seem to have a common understanding of what it entails. Used as synonyms are lobbying, campaigning or communicating to the outside world or referred to the outcomes it should produce changing policy, affirming certain values.</td></tr></table>

Policy development processes are neither linear simple nor always coherent. They often involve the concerted action of multiple agencies with differing interests and are generally influenced by political & economic factors, not all of which are within the public domain. Civil society organizations have been at the forefront of advocating for democracy, good governance and the promotion of human rights. Civil society organizations have lobbied for rights of communities with specific health needs, including consumer lobbies, people with disability, people living with HIV/AIDS. Civil society organisations' information outreach research, advocacy

and legal action; have given visibility to the experience of vulnerable groups and raised important ethical and equity issues around public services for such groups.

Civil society organizations are responsible for developing clearer prioritized strategies, national plan of action, as well as action-research and pilot projects to demonstrate benefits of new approaches in their contribution to increased coordinated avenues for policy development. Members must be given the space, to discuss their expectations and concerns, articulate health needs and define a collective understanding of the activities purpose and
agree on future actions. In this regard, there exists at the health ministries institutional dynamics created by legislation decree or policy where civil society organizations are represented. In spite of their large role of contributing to design of health policy frameworks as highlighted in this review CSO networks are underappreciated by policymakers and scholars. Dialogue between CSOs and the state should be sustained and institutionalized, "given teeth" through strategic plans, legislation or institutions dedicated to managing this sub sector of social policy. Advocacy issues are directly linked to the involvement of CSOs in the sector wide approaches (SWAp) and more generally health issues related to an equitable access to health services.

Civil Society organizations are faced with challenges which include, Inadequate funding, Lack of coordination, Fragmentation of service, Competition and a lack of conducive working environment. Effective partnerships among governments, stakeholders, development partners and civil society organizations are needed. The role of donors as sparing partners between civil society and the state can be more important than funding. Many local civil society organisations are marginalized by government and experience persecution and violation of human rights. In such cases they may mobilize to exert pressure on government through a more independent and critical approach. The policy Window calls for civil society organisations to get into the process early enough.

The process of consultation and participation should be improved through a more structured and consen-

sual mechanism between civil society and the government. There is also need for open disclosure of information and the right to information. The official secrets act, the information and broadcasting act and the prohibited publications act obstruct collaboration in the poverty reduction strategy paper. Sections of these acts limiting participation and consultation should be reviewed or suspended while awaiting amendment.

## Acknowledgement

We acknowledge support provided by Rosalia Opondo Kenya Broadcasting Corporation.

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