Abstract
Accountability problems in Nepal’s Primary Health Care (PHC) system is a long standing, yet neglected, issue. This concern has contributed to the increasing interest in direct engagement of citizens on health service delivery to exact accountability from health service providers. However, little is known about the role of citizens in demanding accountability from the service providers. The purpose of this study, therefore, is to explore the social accountability mechanisms by which citizens voice their concerns about health care services, and to gauge responsiveness to their concerns by health service providers in the PHC setting of Nepal.
Using a case study design, interviewer-administered structured questionnaires were used to collect quantitative data from 400 participants (220 service users, 100 Health Facility Operation and Management Committee (HFMC) members, and 80 service providers) from 22 public health facilities in the Dang District. In addition, 39 qualitative interviews with key informants, six focus groups with community members, and document reviews were conducted. Quantitative data were analysed using IBM SPSS 22. Qualitative data were transcribed, organised, and then analysed using the framework method in QSR NVivo 10.
The questionnaire survey found positive attitudes among participants towards citizen engagement in health service accountability. However, there was little awareness among service users of the existence of the Citizen’s Charter and HFMC. Less than one fifth (15%) of service users had ever heard of the Citizen’s Charter and HFMC. The level of awareness of both mechanisms was varied by sex, caste/ethnicity, and occupation of service users. A great majority of HFMC members (84%) and service providers (90%) had heard of the Charter. Similarly, all of the health service providers had heard of the HFMC.
Overall, this study found that the role of social accountability mechanisms in amplifying citizens’ voice, and in demanding accountability from the service providers in the Dang District PHC system of Nepal, was mixed. The collective accountability mechanisms appeared to be more effective than the individual ones in stimulating citizens’ voice and service providers’ responsiveness. Citizens’ voice, in the form of individual complaints, and depth and breadth of participation, was found to be weak in creating incentives to make the service providers accountable. While it appears that the concerns raised did result in increased responsiveness from the health system in relation to issues such as infrastructure, resource mobilisation, and service planning and development, limited responsiveness was apparent in relation to entrenched issues which are directly related to the performance of the service providers, such as health facility opening hours and staff absenteeism. Hence, the social accountability mechanisms were examples of ‘softer’ forms of accountability.
This study also highlighted the potential for the role of social accountability mechanisms to trigger existing traditional bureaucratic accountability mechanisms of the PHC system to make frontline service providers accountable. This role appeared important in the Dang District context where there was limited authority/sanctioning power and resources with citizens/representatives at the local level to hold service providers accountable.
Different factors related to community, service providers and broader health systems were identified as the factors that influenced the effectiveness of both citizens’ voice and responsiveness from service providers. Firstly, lack of knowledge of service entitlement and information asymmetry, little knowledge of voice mechanisms, citizens’ lack of interest in and attitude towards the health sector, economic, educational and cultural factors, power relationships in the community, lack of authority of the community and ‘exit’ options are community related factors affecting the voice of citizens. Secondly, among the service providers and health facility factors, service providers’ attitudes and support, and the availability of resources affected citizens’ voice and responsiveness. Then, the broader health system factors, such as the lack of health sector decentralisation, political patronage, support for the district health system, and the way voice mechanisms were implemented, were highlighted as factors affecting service provider accountability towards citizens.
This study concludes that the evidence for citizens’ voice in terms of demanding accountability from service providers is weak. The limitations of the social accountability mechanisms in the PHC context do not, however, imply that this option for accountability is not viable and therefore should be abandoned. Instead, the awareness of the different factors influencing citizens’ voice and responsiveness should help in designing improved social accountability mechanisms. Most importantly, this study’s findings highlighted the need for strengthening the voice mechanisms by considering their links to the wider contexts and health systems factors, rather than narrowly concentrating on the tools and mechanisms, to yield positive accountability outcomes. Additionally, the government needs to decide what sort of citizen-state engagement it is seeking. If addressing accountability problems are the aim, then there is a need to address the problem of state-citizen power asymmetry. Although confrontational techniques and imposition of sanctions appear to be solutions for the entrenched accountability problems in the PHC system, joint problem-solving seems a promising mechanism to avoid possible power struggles between citizens and their service providers.
This study contributed new knowledge by providing insight into the comparative effectiveness of collective and individual voice mechanisms in a rural and underdeveloped health care system, and by highlighting the potentials for social accountability mechanisms to trigger existing traditional bureaucratic accountability mechanisms of the PHC system to hold frontline service providers accountable when there was limited authority/sanctioning power with citizens. Furthermore, this study highlighted the possibility of existing community health system networks to strengthen the individual voice (complaint management system) and the need for the effective representation of community voice by community representatives and meaningful participation of marginalised communities to strengthen the collective voice process.
What Nepal has achieved despite the formidable barriers (natural, political and socioeconomic) in the health sector in recent decades is impressive. Existing community health system networks and a successful history of citizen engagement in the health sector are unique strengths of Nepal’s health care system. The recent political changes in the country which have created a more democratic environment supporting the expression of voice can be an important opportunity for strengthening citizen engagement in the health system. The insights obtained from the Dang District study about the actual functioning of voice mechanisms provide a useful knowledge base to plan for greater citizen engagement to achieve the health policy objective of establishing an accountable health care system.