Knowledge Brief Health, Nutrition and Population Global Practice 93387 THE ROLE OF THE PRIVATE SECTOR Improving Voice, Participation and IN REPRODUCTIVE Accountability for Basic Health Services in HEALTH SERVICES IN BANGLADESH Cambodia Ahmed Al-Sabir, Bushra Binte Alam, and Sameh El-Saharty September May 2014 2013 KEY MESSAGES: This note explains how users of health services engage in the delivery of local basic health services. The note discusses voice and accountability in the health sector. It sets out the relevant policy framework and compares this with the reality on the ground, focusing particularly on the nature, scope and role of local agents established to implement formal sector policies for participation, and the formal and informal processes that play out. The note then summarizes the findings and recommendations. Background Voice, Participation and Accountability in The Royal Government of Cambodia (RGC) intends to Health: Findings develop an accountability framework to increase user participation in local governance. The legal and policy The forms of participation by citizens, their ability and framework for decentralization articulates a transformation willingness to articulate their voice, and the nature and of accountability in governance through sub-national scope of accountability by service providers, is shaped by democratic development. It defines vertical, horizontal obscure relations between actors in health. Many actors and downward accountability relationships within sub- have both state and non-state identities and roles. The national councils. It sets out the relationships between 2003 community participation policy for health envisages elected officials and the administrations responsible for a Village Health Support Group (VHSG) and a Health public services, and defines the legal, administrative and fiscal instruments to ensure sub-national administrations Center Management Committee (HCMC). The VHSG and (SNA) function autonomously. In practice, however, the HCMC are defined as the primary vehicles for engaging boundaries of the accountability framework envisaged for local representatives in outreach and awareness building, SNAs are narrow, and mainly apply to the structures of and in the management of the primary health care facility: government under the control of the Ministry of Interior. the health centers. The policy prescribes the membership The health sector does not normally operate within the and roles of these groups and committees at village and same accountability framework, as it is still the commune level. responsibility of its line ministry. While theoretically deconcentrated, representatives placed in provinces and districts mostly operate as centralized, vertical silos, and ‘Community participation’ to health practitioners and few decisions are made at the local level. officials is synonymous with ‘communities cooperating in outreach, campaigns and awareness building’, i.e. getting villagers to join health campaigns that might, for instance, Page 1 HNPGP Knowledge Brief • promote nutrition or maternal health care. The VHSG— councilors will step in only if complaints reach through which the health sector reaches the grass roots in unacceptable levels. villages—is a supply-side vehicle for this mobilization, providing an important outreach and awareness-raising role. Village health volunteers deliver messages to There are functioning upward accountabilities in primary households, perform basic primary care services and, through semi-structured monitoring, obtain information health care that help to keep services flowing and (including community feedback) to pass back to higher improving, and problems are often resolved locally. levels of government. Although few vehicles have been established for voice, the health sector has established internal accountabilities. Service providers are upwardly accountable to the next As a grassroots agent of change, the VHSG is not level, from the village/commune level facilities to the performing a role that mobilizes voice and engagement operational district offices, to the province, and to the for enhanced health service delivery. The VHSG is neither national level. Villagers who are unhappy with the mandated to mobilize voice, nor to hold health service performance of health staff do bring their concerns providers to account; nor is it the right organization to do forward informally, and concerns are then managed so. Acting as an intermediary, the VHSG tends to establish a filter on community voice regarding health locally wherever possible. With few directives to improve, matters, and the village volunteers are bearers and downward accountability is not a priority for health custodians of information. This arrangement does not workers. empower households or communities as users with rights to health care. Given that village volunteers channel feedback, and simultaneously provide outreach services, their role is ambiguous: it is both intermediary and In the absence of a clear mechanism for voice, and as provider. Currently, no other direct mechanism for incomes increase, households often adopt a choice and communities to provide feedback on health services exit strategy, rather than a voice and accountability exists. strategy, to obtain better services. The reality is that the public health system only served 25 percent of those seeking treatment for illness in 2010 (Martinez, 2011). Rather than negotiating informal and mediated voice The HCMC is a multi-stakeholder group of government mechanisms, households who can afford to, opt out of actors and service providers that plays neither a services provided by government and seek primary health management role nor an oversight role, but functions as a care from alternative providers. This has implications for support committee. In practice, the chief of the health the regulation of private health (e.g. dual practices, center plays a key role in the HCMC. Moreover, the unlicensed drug sellers) and the inclusion of these intertwined membership of the committee (mixing service providers in governmental oversight arrangements, as providers and community leaders) promotes a consensus- well as opportunities for a shift to demand-side financing driven approach. The HCMC is not managing or mechanisms (CCTs, scholarships, vouchers etc.). overseeing, but generally supporting the HC chief. The HCMC and the VHSG are also constrained by low incentives and limited capacities, challenges that have only been overcome where external, typically NGO, Voice and accountability mechanisms in relation to support is present. primary health services have proven successful when stimulated through external agents, such as NGOs, who create space for voice. Fieldwork confirms that NGOs make a difference in the levels of voice and The HCMC policy envisages a key role for commune accountability, through monitoring efforts and providing councilors to help manage health centers (including space for citizens to give feedback. These initiatives planning, setting user fees, and managing budgets). In stimulate the direct participation of users, and mobilize the practice, however, commune councilors nominated to the commune council as convener and driver of change. HCMC limit their involvement due to a lack of time and an unclear mandate. Currently, their mandate comes from the policy that they chair the HCMC, but it is also established through their poverty reduction mandate. An Partly because it is focused on mobilizing communities to overriding unwillingness to create discord locally limits participate in campaigns, the policy for community any action that might hold to account health workers, and participation in health does not empower users to participate, or empower them with information. A number Page 2 HNPGP Knowledge Brief • of attributes constrain the way the community participation citizens to meetings. policy functions. It currently does not provide space for users to voice feedback independently and safely. It sets up roles for local leaders, the local elite and quasi- (ii) Multi-stakeholder groups/committees with officials, and reinforces existing balance of powers. This confused mandates include both service fails to empower the poor. Little information flows within providers and community leaders/elite the communities about health services (standards, together, (e.g. village health volunteers, policies, budgets, targets and/or performance). The school directors sit beside village chiefs, nature of these groups/committees reinforces the elders (archas), commune councilors on consensus-driven approach adopted at the local level to these committees at village, commune and decision-making and conflict resolution. In practice, a district levels) playing various service provider primary interest is that relations are harmonious. and supporting roles. Organizational structures are created, not for the purpose of enhancing voice or accountability, but for the purpose of building accord among stakeholders through compromise. There are some fundamental gaps in Participation in planning is constrained by the minor knowledge and awareness of the role of users in a nature of decisions made at the local level, and there is participatory process that is distinct from leaders and almost no participation in monitoring. Decision-making at service providers. Health policies have not been the commune level for local basic services can be coordinated, and only weak linkages exist between the extremely limited in scope, as health is deconcentrated, participatory processes for commune planning and annual not decentralized. Even if participatory mechanisms were decision-making for health centers. The District well-designed, there is a limit to how much input users Integration Workshop (DIW) provides an opportunity for can provide at the planning stage. A critical gap for user coordinating local level activities, but does not include engagement is the scope for engaging in other (non- coordination or discussion about the engagement of planning) processes, e.g. monitoring of service provision citizens in development processes. that enable users to engage directly on matters that affect them. A lack of demand for participation, even where opportunities exist, is common in Cambodia and relevant Users do articulate their voice occasionally in events with to the discussion on voice in basic services. Users often clearly defined rules and facilitation (e.g., formal do not desire a platform for voice. Moreover, both officials workshops arranged by external parties). These situations and citizens lack any belief that inclusive arrangements provide alternative vehicles for communication that have will make a difference. Villagers make rational decisions been endorsed by the normal players. Typically users are on where they should focus effort to improve their lives unaware of what to expect in terms of their rights or and it is unlikely they would try to influence policy or the agreed standards of service (e.g. hours of opening of small budgets for deconcentrated services. These health centers, drugs that should be available). They historically and culturally sustained social structures are make judgments on what is unacceptable, and voice their nevertheless subject to change under specific opinions only rarely, when they perceive mismanagement circumstances. This lack of demand is generally to have gone too far. In these bottom-line cases, protests exacerbated by a lack of access to information. are loud and caution is cast aside. Communities do not know what standards of service to expect or what the budgets are for services. At the local level, users are reluctant to articulate their voice, but if Increasing incomes and levels of awareness are enabling they do, they do so through two types of intermediaries: households to decide to go to a different health center or an alternative provider. This could change the structures of primary health services, and have significant (i) Small, invited groups/committees are implications for regulation, financing and voice. This comprised of a few active individuals, mostly ’opting out’ could affect those lef t (normally the poorest elite members of the community, who usually households), weakening the collective voice, and slowing serve in a multitude of similar bodies. Actors improvements in public services. are benevolent and informed, but non-elected and non-representative, many in quasi-state roles. They hear about issues informally, and then carry, and filter, the voice of ordinary Recommendations Page 3 HNPGP Knowledge Brief • • Processes for voice and engagement need significantly affecting local accountabilities. Policy clarification in health policies and as they are dialogue is needed to clarify relationships revised policies should be coordinated as between line ministry staff and elected commune much as possible. Participation policies should councilors (given their poverty reduction make a clear distinction between community mandate). participation for the purposes of outreach campaigns and the forms of citizen engagement • Health center workers require significant that promote voice and accountability. The attitudinal change and capacity development operationalization of the SNDD social to improve downward accountability. As accountability framework provides a potential providers of health services they need to develop platform to develop this clarity and ensure local a conceptual understanding and practical level policy and practices are aligned, and knowledge of downward accountability. reinforce each other. • Functional assignment offers an opportunity to change accountabilities in service delivery. • The structure, membership and functions of The current process of functional mapping and the groups/committees at the local level is proposed delegation of functions to communes currently limiting the space for voice and and districts offer an opportunity to develop blurring the lines of accountability. At the demand-side processes involving users and grassroots level, the separation between those elected councilors, as well as lowering the level of that provide a service, and the users of the decision-making around aspects of service service, is critical. A distinction between delivery. management and oversight functions is also urgently needed. Local level committees (HCMC and VHSG) require review and clarification of their • Monitoring and evaluation (M&E) should roles, responsibilities and functions, especially include monitoring voice and accountability. with a view to enhancing empowerment and M&E systems should include simple indicators on engagement of ordinary citizens and establishing the degree of meaningful user engagement. local accountabilities. These can be measured through perception surveys, community scorecards or through third party monitoring. • Participatory spaces that encourage voice and engagement must be pro-actively developed and sensitively implemented. Given that • The role of non-state actors as outside citizens generally avoid engaging with the state, facilitators of voice and accountability is and that the benevolent attitudes of the elite emerging, but a strategy for scaling up needs members of the community dominate local to be formulated. The role of external facilitators dynamics, it is essential that safe spaces for voice is key to ensuring that processes are inclusive and engagement are found at village level. (women, youth, or vulnerable groups) and Mechanisms for sensitive and independent empowering users. Impact evaluations need to facilitation will be critical. be carried out to see what works, when, where and why. Moving forward, sustainable funding approaches are needed to facilitate participation • The mandate of the Commune Council in and empowerment processes. supporting, monitoring and overseeing local basic services needs to be clearly and • Policy needs to respond to the growing trend consistently defined in both council and Ministry of Health procedures. In practice, for users of health services to exercise “choice� and obtain services from alternative commune councilors play vastly different roles. providers. While users can vote with their feet, While some councils hold health providers to the burgeoning market of private providers needs account for the quality of the services they provide appropriate regulation (e.g. dual providers). in a commune, other councilors rubber- stamp decisions by Health Center management Page 4 The Health, Nutrition and Population Knowledge Briefs of the World Bank are quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, please contact Miguel Sanjoaquin, Health Economist (msanjoaquinpolo@worldbank.org) Page 5 Page 5