“Free healthcare, free die”
The efficacy of social accountability interventions in the health sector in Sierra Leone
Pieternella M. Pieterse, BA (Hons), M.Phil. Peace Studies
PhD Thesis University of Limerick
Supervised by Professor Tom Lodge and Dr. Chris McInerney
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Abstract
“Free healthcare, free die”
The efficacy of social accountability interventions in the health sector in Sierra Leone
Pieternella M. Pieterse
Since the beginning of the 21st century, aid donors, NGOs and development research institutions have turned their focus to the question of how the quality of basic public service delivery in developing countries can be improved. While it has become clear that the most important factor in the improvement of services is tackling problems related to the workforce that provides public services, it has not been easy to find effective ways to improve the standards of, for example, health and education services by changing the behaviour of public service providers.
One approach which has received a lot of attention, and is now being used worldwide, is the use of ‘social accountability’. A myriad of social accountability approaches exist: many focus on citizen-service provider dialogue, others encompass participatory planning processes at district or even national level, or track how budgets are being spent. This study examines a sub-section of social accountability practice, and focuses specifically on interventions that aim to improve primary health service delivery.
Social accountability methodology has evolved greatly over the past decade, and our understanding of why certain interventions work better than others has been enhanced by a greater focus on contextual influences and a deeper understanding of the power dynamics and politics that have an impact on service delivery decisions. However, while the technical and academic understanding of practical social accountability failures has improved, many of those who are engaged in the practice of social accountability have yet to catch up.
This research aims to provide a greater understanding of the realities and the challenges faced by NGOs, CSOs and individuals who are involved in implementing social accountability interventions. By examining a series of social accountability interventions in Sierra Leone, a country with weak governance and high levels of corruption, this study provides a unique insight into the dichotomy between the advanced policy guidance that is available within the world of social accountability research, and the messy reality of social accountability implementation in a fragile state environment. This study ultimately provides a simple framework which outlines six key components that need to be taken into account for the design or evaluation of a social accountability intervention. While this is no failsafe solution to the challenges of designing a social accountability intervention, this framework, and the narrative account of four social accountability interventions in the health sector contained within this thesis, aims to narrow the gap between practitioners and theorists of social accountability.
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Declaration
I declare that the work in this thesis is the work of the candidate alone and has not been submitted to any other University or higher education institution in support of a different award. Citations of secondary works have been fully referenced.
A journal article based on the primary research carried out for this thesis has been published under the following citation:
Pieterse, P. and Lodge, T. (2015) ‘When free healthcare is not free: Corruption and mistrust in Sierra Leone's primary healthcare system immediately prior to the Ebola outbreak’, International Health 7(6).
Signed:
Date:
Pieternella M Pieterse
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Acknowledgements
This study would not have been possible without the many women in Sierra Leone who generously gave up their time to talk to me about the healthcare they received. I am equally indebted to the many health workers, health authority staff and the many other NGO, CSO and UN staff whom I interviewed during my field work. My research could not have taken place without the support of Christian Aid Ireland, Alix Tiernan and Karol Balfe in particular, thanks to whom I had the best research collaboration experience I could have hoped for. I also thank the Christian Aid Sierra Leone staff, especially Joseph Ayamga, for their support. I also thank the staff of SEND Foundation, in particular the inspiring Siapha Kamara, and the NMJD staff, for their time and patience while showing me around Kailahun and Kono Districts. I also thank the Concern country director Marianne Byrne and her team for facilitating my visit to the clinics in Tonkolili. I am grateful that Sarah Dykstra and Caroline Fry of IPA, and Margaux Hall of the World Bank, were so kind to help me to obtain permission from the World Bank to conduct interviews in Tonkolili while their own RCT research was still ongoing. Furthermore I thank my friend and, at the time, fellow PhD candidate and ambassador Sinead Walsh for putting me up in Freetown every time I passed through and for her sound advice about Sierra Leone and PhD research.
This thesis has greatly benefited from the guidance of three individuals at the University of Limerick. I thank Prof. Tom Lodge, especially for his encouragement at the beginning of my research, when I really wasn’t sure if doing a PhD was for me. I am also thankful for the advice from Dr. Rachel Ibreck, who was my co-supervisor for a year, and whose friendship and support outlasted her departure from UL. Finally, I am immensely grateful to Dr. Chris McInerney, who was my co-supervisor during the second half of this research project and whose support was instrumental in helping me get this thesis finished. I also thank my fellow PhD students at the Department of Politics and Public Administration, Sarah Hunt, Helen Basini and Caitlin Ryan for their friendship and support, which has endured since their graduations and my move to Ethiopia.
I could not have completed this study without the financial support from the University of Limerick’s Registrar’s Bursary. I am thankful for the opportunity it has offered me to carry out this research.
I thank my friends in Newport, Co. Tipperary and Addis Ababa, Ethiopia, and further afield, for putting up with my endless chat about social accountability. In Addis Ababa, I also thank my friends from our ‘long-distance PhD-ers support group’, my ESAP2 colleague and ‘SA sounding board’ Lucia Nass, and Isabelle Clevy-O’Hara, for their comments and suggestions.
On a personal level, I thank my husband Paul who supported me all the way to take on this project and stick with it: thanks for the many hours of additional child minding you took on without complaining, so that I could travel or study. Thank you Eva, Orla and Finn for understanding that your mum was also a student who needed peace and quiet to get chapters written when you wanted me to go to the pool, read or play Lego with you. v
Contents
Abstract ...... iii Declaration ...... iv
Chapter 1 - Introduction ...... 1
1.1 Overview and rationale ...... 1 1.2 Research aims and significance ...... 5 1.3 Chapter Synopsis ...... 8
Chapter 2- Literature review ...... 13
2.1 Research questions and the literature ...... 13 2.2 Accountability and social accountability literature ...... 15 2.3 Social accountability and corruption literature ...... 42 2.4 Human resources for health literature ...... 47 2.5 Conclusion ...... 55
Chapter 3 - Methodology ...... 59
3.1 Introduction ...... 59 3.2 The analytical framework for social accountability interventions ...... 60 3.3 The research design ...... 71 3.4 Data collection overview ...... 85 3.5 Data analysis ...... 105 3.6 Conclusion ...... 106
Chapter 4 - Sierra Leone’s challenging operational environment ...... 109
4.1 Introduction ...... 109 4.2 Setting and historical context ...... 110 4.3 Sierra Leone’s governance and administrative constraints ...... 121 4.4 Civil society‘s role and capacity in post war Sierra Leone ...... 127 4.5 The Free Healthcare Initiative ...... 131 4.6 Conclusion ...... 145
Chapter 5 - Case Study A: Community Monitoring with Score Cards ...... 149
5.1 Introduction ...... 149 5.2 Tonkolili District ...... 150 5.3 Case Study A: Community Monitoring ...... 153 5.4 Assessing the Community Monitoring intervention ...... 158 5.5 Analysis ...... 175 5.6 Conclusion ...... 187
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Chapter 6 - Case study B: Non-Financial Awards ...... 189
6.1 Introduction ...... 189 6. 2 Case Study B: Non-Financial Awards ...... 190 6.3 Assessing the Non-Financial Awards intervention ...... 193 6.4 Analysing the Non-Financial Awards intervention ...... 204 6.5 The findings from the ‘control’ interviews and case studies ...... 211 6.6 Conclusion ...... 225
Chapter 7 - Case study C: Participatory Monitoring and Evaluation ...... 227
7.1 Introduction ...... 227 7.2 Setting and historical context: Kailahun District ...... 228 7.3 Case C: Participatory Monitoring and Evaluation ...... 231 7.4 Assessing the Participatory Monitoring & Evaluation intervention ...... 240 7.5 Analysis...... 255 7.6 Conclusion ...... 262
Chapter 8 - Case Study D: Mixed Methods with Quality Service Circle ...... 265
8.1 Introduction ...... 265 8.2 Setting and historical context: Kono district ...... 266 8.3 Case D: Mixed Methods, including Quality Service Circle ...... 269 8.4 Assessing the Mixed Methods with Quality Service Circle intervention ...... 272 8.5 Analysis...... 295 8.6 Conclusion ...... 303
Chapter 9 – Comparative Analysis...... 305
9.1 Introduction ...... 305 9.2 Comparing the case studies using the analytical framework ...... 307 9.3 Gaps in the literature ...... 340 9.4 Creating a new social accountability model ...... 349 9.5 Conclusion ...... 352
Chapter 10 - Conclusions ...... 355
10.1 Introduction ...... 355 10.2 Summary of the thesis ...... 357 10.3 Addressing the research questions ...... 358 10.4 The limits and added value of social accountability interventions ...... 365 10.5 Contributions of the study ...... 370 10.6 Implications for further research ...... 373
Post script: Ebola …………………………………………………………….……377
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List of figures, tables and appendices
Figures Figure 1: The 'Accountability Triangle' ...... 2 Figure 2: The social accountability family tree ...... 23 Figure 3: Map of Sierra Leone with district boundaries ...... 78 Figure 4: The researcher gets ready to start focus group discussion, Tonkolili District ...... 90 Figure 5: Diagram of entities involved in CM and NFA RCT ...... 155 Figure 6: Illustration of incidence of alleged charging for free care, raised during FGDs ...... 164 Figure 7: Illustration of incidence of alleged charging for free care, raised during FGDs ...... 197 Figure 8: Illustration of incidence of alleged charging for free care, raised during FGDs ...... 215 Figure 9: Photo of a sign board declaring this clinic a MDG awards winner ...... 236 Figure 10: Trucks stuck on the muddy Pendembu-Kailahun road ...... 244 Figure 11: Illustration of incidence of alleged charging for free care, raised during FGDs .... 246 Figure 12: Illustration of incidence of alleged charging for free care, raised during FGDs .... 283 Figure 13: Power imbalance between health worker and citizens – levelled by DHMT or NGO presence ...... 327
Tables Table 1: A mapping of variables based on factors that indicate or contribute to the marginalisation of three districts: Tonkolili, Kono and Kailahun...... 81 Table 2: Sampling data for this study ...... 87 Table 3: Overview of interview and focus group data gathered ...... 93 Table 4: Redressing the information imbalance ...... 308 Table 5: Citizen Participation ...... 317 Table 6: Power and political awareness ...... 325 Table 7: Sustainable staff motivation ...... 331
Appendices Appendix A: Interview and focus group discussion guidelines…………………..…………413 Appendix B: Interview and focus group discussion reference codes……………….….……419 Appendix C: Schedule of feedback sessions and conference presentations…………….…..422 Appendix D: NVIVO10 Final coding matrix………………………………….…………….424 Appendix E: PM&E survey questionnaire (sample of first 8 pages)……….….……………429
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Acronyms
APC All People’s Congress (Sierra Leone political party)
BPEHS Basic Package of Essential Health Services
CAI Christian Aid Ireland
CASL Christian Aid Sierra Leone
CHC Community Health Centre
CHP Community Health Post
CHMVG Community Health Monitoring Volunteer group
CM Community Monitoring (with Score Cards)
CSO Civil Society Organisation
DAH Development Assistance for Health
DBOC District Budget Oversight Committee
DHMT District Health Management Team
DMO District Medical Officer
FGD Focus Group Discussion
FHC Free Healthcare
FHCI Free Healthcare Initiative
FMC Facility Management Committee
GoSL Government of Sierra Leone
GPSA Global Partnership for Social Accountability
HFAC Health for All Coalition
IDS Institute for Development Studies (University of Sussex)
INGO International Non-Governmental Organisation
IMF International Monetary Fund
IPA Innovations for Poverty Action
KWiG Kailahun Women in Governance
MCHP Maternal and Child Health Post ix
MCH Aide Maternal and Child Health Aide
MDG Millennium Development Goals
M&E Monitoring and Evaluation
MM/QSC Mixed Methods/Quality Service Circle
MoHS Ministry of Health and Sanitation
NFA Non-Financial Awards
NGO Non-Governmental Organisation
NMJD Network Movement for Justice and Development
ODI Overseas Development Institute
PBF Performance Based Finance
PFM Public Financial Management
PHU Peripheral Health Unit
PMDC People’s Movement for Democratic Change (Sierra Leone political party)
PM&E Participatory Monitoring and Evaluation
QSC Quality Service Circle
RCT Randomised Controlled Trial
RUF Revolutionary United Front
SEND Foundation Social Enterprise Development Foundation
SLPP Sierra Leone People’s Party (Sierra Leone political party)
TBA Traditional Birth Attendant
UN United Nations
UNDP United Nations Development Programme
VHC Village Health Committee
WHO World Health Organisation
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Chapter 1 - Introduction
1.1 Overview and rationale
“Too often, services fail poor people - in access, in quantity, in quality.”
This is the opening line of the 2004 World Development Report titled “Making
Services Work for Poor People” (World Bank 2004). The theme of the report, poor people’s lack of access to basic services, was chosen with the objective of highlighting one of the most pressing issues which the authors envisaged would hamper the achievement of the newly conceived Millennium Development Goals. One of the key tenets of the report, which made it a seminal publication, was to advocate “putting poor people at the center of service provision: by enabling them to monitor and discipline service providers, by amplifying their voice in policymaking, and by strengthening the incentives for providers to serve the poor” (2004, p. 1). The report contained some frank admissions about failures in the foreign aid chain; foreign donors provide assistance to developing countries with a view to lifting them out of poverty, but developing country governments do not invest enough in ensuring that the public services they provide reach the poor. The solution proposed in the report was “[…] to strengthen accountability in three key relationships in the service delivery chain: between poor people and providers, between poor people and policymakers, and between policymakers and providers” (2004, p. 1).
The report furthermore introduced the notion of both long and short routes of accountability: the ‘long route’ implied the tenuous path through which a citizen,
1 unhappy with the services she or he receives, can influence its improvement by appealing to policy makers to sanction service providers. The authors of the report suggested that “Given the difficulties in strengthening the long route of accountability, improving the short route - the client-provider relationship - deserves more consideration” (2004, p. 9), and furthermore provided the much replicated accountability triangle (see figure 1).
Figure 1: The 'Accountability Triangle', the World Bank’s 'Framework of accountability relationships' While the report was not exactly (2004, p. 6) the starting gun for the
implementation of development
aid interventions that began to
focus on accountability in public
service provision (some of these interventions had already started, but they were few), it did capture the mood of the time and paved the way for development actors’ increasing engagement in
‘accountability interventions’.
The mood of the time that led to the reconceptualization of the poor’s lack of access to services as a ‘failure of accountability’ was one in which development actors and donors found themselves caught up in a confluence of new development thinking: the
Washington Consensus was on the wane (Gore 2000, Rodrik 2006), the rights-based approach to development was on the rise (Sen 2001, Sengupta 2002), and the introduction of the Millennium Development Goals focused the minds of aid donors and recipients on linking aid spending to achieving measurable results (Barder 2012,
Klingebiel 2011). Aid harmonisation was increasingly mooted as a more effective way to delivery aid (de Renzio et al 2005, Rogerson 2005), and in aid-receiving countries, 2 budget support briefly became the preferred modality of aid transfers (Lawson et al
2005) based on the assumption that foreign aid delivered straight into the exchequer would be most effective at supporting government systems to sustainably deliver public services.
The new focus on accountability was the product of all of these new ways of thinking: the thrust of the arguments was that developing country governments should be supported to deliver services to its people, but the services should be better than before: increased quantity, better quality and more equitable services for the rich and the poor alike (after a decade in which donors had been advocating state downsizing and the contracting out of public services). International NGOs should move away from delivering services but could instead find a role in supporting citizens to demand better services, both at the planning stages and at the places where they encounter frontline service providers.
In the past decade, a growing accountability-focused development practice has emerged. It has grown into a range of sub-disciplines that focus on accountability at different levels: there are national level and policy level accountability interventions; there are district or province level planning focused interventions and there are programmes that are more focused on budgets. Finally, there are those interventions that focus on frontline service delivery, the subject of this thesis.
Accountability deficits at the frontline service provider-level have most prominently been met by a range of interventions that focus on the empowerment of citizen and the amplification of their voices to demand greater accountability from service providers.
This emphasis on social pressure from citizens soon earned the name ‘social
3 accountability interventions’. While there are many more terms that depict these interventions, I will use ‘social accountability interventions’ throughout this research.
The literature on social accountability has grown steadily in the past decade, reflecting the ever increasing use of its methodologies. The literature has also evolved significantly, from what was a very technical and practically focused field until around
2010 (Acosta et al 2010, Fiszbein et al 2011, Gaventa and Barrett 2010, Holland et al
2009, Joshi 2010a, 2010b, Malena et al 2004, McGee and Gaventa 2010, McGee and
Gaventa 2011, O’Neil et al 2007) to a body of literature that focused more on the circumstances under which social accountability interventions succeed or fail. Many of these texts are more introspective and politically aware (Fox 2014, Joshi and
Houtzager 2012, McGee and Kroesschell 2013, Rocha Menocal 2014, Tembo 2013,
Wild and Foresti 2013). The early literature was informed by the first social accountability interventions that could be documented (Arroyo and Sirker 2005,
Malena and Forster 2004, Shah 2003), and often served a dual purpose of offering the reader a programme review as well as guidance for implementation. As social accountability interventions became more widespread, the social accountability literature moved away from its prescriptive ‘how to’ tone and became more critical and also more academic in nature.
As the literature on social accountability evolved, authors started to raise more complex and critical questions that have deepened our understanding of factors that undermine the success of social accountability interventions. This has strengthened the knowledge about the range of methods that have been used, and the types of outcomes that have been achieved. However, as the literature on social accountability has become more complex, it has also moved away from its close ties with implementation
4 practice. The language has evolved from ‘how to’ to ‘ought to’ and it has become increasingly more likely that complex contextual questions are debated in London or
Washington D.C. rather than Kampala or Kathmandu.
While the social accountability literature moved to a more conceptual phase, social accountability practice moved from being a methodology primarily used in stable and relatively democratic contexts, to being implemented in more complex environments such as in highly corrupt, fragile or conflict affected states. Practical guidance for these more challenging kinds of implementation environments is rare, as is practical guidance on the more recent conceptual trends in social accountability literature such as ‘strategic social accountability’ (Fox 2014).
1.2 Research aims and significance
This study was conceived in order to contribute to filling the gap that has emerged as high level debate and academic discussion on social accountability has accelerated
(Carothers 2016, Fox 2014, Guerzovich 2015) leaving practitioners behind. These debates often highlight the need for social accountability practice to be more strategic, more politically aware and context sensitive, without providing guidance for practitioners on how to design and implement exactly such strategic, politically aware and context sensitive social accountability programmes.
In 2014/5, two series of publications that once again focused on the ‘how to’ of social accountability emerged. Both series provide practical examples of how citizen feedback and social accountability interventions can be designed and implemented.
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One such series was the result of collaboration between the Centre for Devolution
Studies - Kenya School of Government and the World Bank, while the other was a series that emanated from the Global Partnership on Social Accountability, another
World Bank initiative. The latter series was prompted by the receipt of 600 funding applications to the Global Partnership for Social Accountability’s grant making division. Many proposals were left unfunded because they were drafted without the required programme design know-how that could circumvent some of the obvious political economy challenges that social accountability interventions inevitably encounter. The authors admitted that “the majority of the proposals, many of which had good ideas, did not contain the basic building blocks of a strategic social accountability intervention”, recognising that, just because several papers have been published about these new approaches, it does not mean that practitioners are aware of them or know how to translate these concepts into a social accountability programme design (Guerzovich and Poli 2014a).
This study aims to shed light on what implementing some of the more recent concepts of improved social accountability methodologies looks like in practice. It also aims to contribute to an emerging body of literature that examines some of the more recent experiments with social accountability methods in complex environments (Ho et al
2015, McGee and Kroesschell 2013, Tembo 2013).
Sierra Leone was chosen as the location to conduct a comparative case study analysis of four social accountability interventions in the health sector. In 2012, when this research started, Sierra Leone’s civil war had come to an end exactly one decade previously. The country has made some remarkable progress since then (Mitton 2013), but high levels of corruption continue to hamper equitable basic service delivery and
6 undermine the government’s legitimacy (Acemoglu et al 2014, Fanthorpe and Gabelle
2013, Transparency International 2013). In 2010, the government of Sierra Leone introduced the Free Healthcare Initiative, which offers access to a basic package of free health services to pregnant and lactating mothers and to children under five
(Government of Sierra Leone 2010). Subsequent problems with continued charging for free care and missing medical supplies (Amnesty International 2011, Bhandari 2011,
Maxmen 2013) led to the introduction of a significant number of social accountability interventions. These interventions, along with other basic monitoring interventions, all had the same goal: the improvement of accountability in the health sector. In 2012, when this research project began, social accountability interventions in the health sector were being implemented simultaneously throughout Sierra Leone, enabling me to design a comparative study of different methods in similar settings. Sierra Leone provided the opportunity to research the efficacy of social accountability interventions in a challenging operational context. The different methods allowed the study to examine what it means in practice for an intervention to “embrace contextual dynamics” (Tembo 2012) as some of the interventions did, or to take a “strategic social accountability” approach (Fox 2014) – as one of the programmes did.
The following research questions were used to guide the study:
(i) Why and when do social accountability interventions aimed at improving public service delivery, succeed or fail?
(ii) What effects do social accountability interventions have on frontline staff in healthcare facilities?
(iii) How can social accountability methodology be improved?
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For this research project I consciously sought to collaborate with two international
NGOs, Christian Aid and Concern Worldwide, which allowed me to gain access to the sites where their local partner organisations implemented the social accountability interventions that were the focus of this study. The collaboration with the two agencies provided great insights into the extent to which international NGOs accessed policy guidance on social accountability and took part in the intellectual debates regarding, for example, contextual implementation challenges. Over a year of work experience as a research consultant for the Ethiopia Social Accountability Program – phase 2, furthermore enhanced my understanding of the dichotomy between the conceptual dilemmas debated by the programme designers and the implementing agencies’ struggle to understand, for example, what a ‘gender disaggregated focus group discussion’ is.
1.3 Chapter Synopsis
To explore the research questions posed this thesis is structured as follows:
Chapter Two offers a survey of the literature that was used to inform this research. It contains an overview of the social accountability literature and demonstrates which of the methodological components keep reoccurring within the review and studies of the most successful interventions. The three most prominent components are selected as parts of the emerging analytical framework for social accountability interventions which will guide the empirical study and subsequent data analysis. Chapter Two furthermore contains a brief examination of two other bodies of literature that are also
8 relevant to this study; these are the literature on corruption and the literature on human resources for health. The fourth and final component of the analytical framework is derived from the latter texts.
The methodology chapter (Chapter Three) operationalises the four key themes of the analytical framework for social accountability interventions, which were derived from the literature review. The four components are: i) redressing information imb alance, ii) citizen participation, iii) power and political awareness, and iv) sustainable staff motivation. The research methodology and sampling consideration are also found in chapter three, as are a range of data collection-related issues that are relevant to the study.
Chapter Four focuses on Sierra Leone, the country that provides the backdrop to this study. Chapter four starts with a brief overview of Sierra Leone’s history. The chapter then expands to examine the country’s governance and administrative constraints, before providing details about the 2010 introduction of the Free Healthcare Initiative.
The final section of this chapter highlights the capacity challenges faced by Sierra
Leone civil society organisations that monitor the rolling out of the free healthcare policy.
Chapter Five presents an examination of Tonkolili District, where the first case, the
Community Monitoring with Scorecards intervention (CM) programme was located.
This section starts with an introduction of the CM methodology, followed by a closer look at the implementation challenges faced by the CSOs that used this method. The chapter furthermore presents the findings derived from focus group discussions, interviews as well other relevant documentation. The chapter closes with an examination of the CM method, using the analytical framework. 9
Chapter Six contains an examination of the second case, which focused on the Non-
Financial Awards (NFA) intervention. Like the CM method, this intervention was also implemented in Tonkolili District. Chapter Six starts with an introduction of the methodology used and provides an overview of the implementation challenges that were encountered. The chapter furthermore provides the most significant data from the interviews and focus group discussions conducted in the locations where the NFA intervention was implemented. To finalise the NFA-focused section, the analytical framework is used to examine the method in detail.
Chapter Six contains details of an additional set of research interviews and focus group discussions which were conducted in Tonkolili District. This small cluster of data was gathered in clinics where no social accountability intervention took place and can therefore be considered a control sample.
Chapter Seven and Chapter Eight follow a similar pattern; the chapters contain an examination of the third and fourth methodologies studied for this thesis. Chapter
Seven introduces Kailahun District, the location where the Participatory Monitoring and Evaluation (PM&E) intervention was implemented. Chapter Eight starts with details about Kono District, where the Mixed Methods with Quality Service Circle
(MM/QSC) was implemented. The chapters proceed with details of the PM&E or the
MM/QSC methodology and highlight the implementation challenges that were encountered. This is followed by data from the interviews and case studies conducted in Kailahun and Kono respectively, and the chapters close with an examination of the methodologies using the analytical framework.
Chapter Nine is the analysis chapter, which starts off with a comparison of the four social accountability methods under study, using the analytical framework. Having 10 drawn conclusions about which interventions were more successful than the others, the focus then shifts to an examination of the analytical framework.
This chapter reflects on whether the emphasis within existing social accountability literature adequately engages with all components that are required to design and implement a social accountability intervention that is well suited to the environment in which it will be implemented. The chapter concludes with the inclusion of the ideal design of a social accountability intervention suited to the Sierra Leone context, but which could easily be adapted to different implementing environments.
Chapter Ten is the final chapter that brings together the conclusions of this research project. The chapter contains a summary of the research findings and addresses the three research questions. It touches on the success of the interventions that focused on top-down monitoring and reflects on why the interventions that took a community- health worker dialogue approach were less successful. The point is made that while the latter may have been less successful in these instances, it does not mean that there is no place for such approaches in an implementing environment such as Sierra Leone, but that more research is needed to explore its efficacy in other fragile settings.
Furthermore, the analytical framework is scrutinized and updated for use as a generalizable tool for the design or the evaluation of social accountability interventions in future.
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Chapter 2- Literature review
2.1 Research questions and the literature
This literature review seeks to establish a theoretical framework to address the key research question:
(i) Why and when do social accountability interventions aimed at improving public service delivery, succeed or fail?
From the literature, and the field research, two further research questions will be addressed:
(ii) What effects do social accountability interventions have on frontline staff in healthcare facilities?
(iii) How can social accountability methodology be improved?
This review will start by examining the existing social accountability literature, asking where it is situated and what assumptions underlie its thinking. It will critically assess both the earliest material and the more recent commentary written about social accountability. This review will then broaden its scope to two different literatures that are equally relevant to this research: literature on corruption and literature specific to the health sector, focusing predominantly on human resources for health.
When the different literatures are assessed, it is evident that the literature on social accountability has a tendency to look downwards and concentrate on what is happening at grassroots level, focusing primarily on citizen, and the citizen - service
13 provider relationship. Corruption literature predominantly looks up towards higher levels of government, taking the political economy and the larger external environment into account. The literature on human resources for health tends to look horizontally, focussing predominantly on the health sector. This review argues that a theoretical framework needs to incorporate all three literatures to make sense of the interrelated issues that are relevant to the implementation of social accountability interventions.
This chapter will start by looking at the concept of accountability before introducing social accountability. It will then examine the current literature on social accountability, situating it in a larger body of development literatures on citizenship and participation, power and politics. This section contains an analysis of the most recent debates in social accountability literature and touches on how the literature has evolved. Sections 2.3 and 2.4 give overviews of some of the literature on corruption and human resources for health, limiting this to just those sub-sections of these literatures that are most relevant to social accountability. Section 2.5 concludes by highlighting the key issues that have been identified in this chapter as important to the implementation of social accountability interventions.
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2.2 Accountability and social accountability literature
2.2.1 Accountability as a starting point
Accountability is central to social accountability. However, defining what exactly accountability means, is not straightforward. Schedler believes that accountability is inextricably linked to the notion of power and politics:
Since ancient philosophy, political thinkers have worried about how to keep power under control, how to domesticate it, how to prevent its abuse, how subject it to certain procedures and rules of conduct. Today, it is the fashionable term "accountability" that expresses the continuing concern for checks and oversight, for surveillance and institutional constraints on the exercise of power. (Schedler 1997, p. 1)
In the context of the democratic state, the main accountability relationships are those between the citizens, elected politicians and the bureaucracy that provides the public services that citizens are entitled to (Mulgan 2000, p. 556). Accountability, many argue, is made up of several aspects: To be accountable is to be answerable to questions about what decisions were made and why, and what actions were taken and why - why not (Ackerman 2005b, Bovens 2007, Mulgan 2000, Naidoo 2004). This involves being open about how business is conducted, whether it is government business or the provision of public services. Bovens, writing in a handbook on public management, offers the following definition, along with some interesting musings on the current use of the word accountability:
Public accountability is the hallmark of modern democratic governance. Democracy remains a paper procedure if those in power cannot be held accountable in public for their acts and omissions, for their decisions, their policies, and their expenditures.
As a concept, however, “public accountability” is rather elusive. It is a hurrah-word, like “learning,” “responsibility,” or “solidarity” - nobody can be against it. […] Nowadays, accountability has moved far beyond its bookkeeping origins and has 15
become a symbol for good governance, both in the public and in the private sector. Moreover, the accounting relationship has almost completely reversed. “Accountability” does not refer to sovereigns holding their subjects to account, but to the reverse, it is the authorities themselves who are being held accountable by their citizens. (Bovens 2005, p. 182)
An analysis of these definitions shows that accountability alone does not actually force individuals to act in ways that conform to the standards expected of them; accountability prompts individuals to be transparent about their work or their behaviour, which, in an ideal scenario, often leads to improvements in professional conduct, presumably as individuals fear being exposed as having produced substandard work or embezzled funds. However, ‘what it means to be accountable’ often goes unexplored in literature. It appears that the notion of ‘acting accountably’ has taken on the meaning of persons not only ‘being transparent about their conduct, but also about adjusting their actions and decisions, and, particularly in the work place, being virtuous’ (Bovens 2010). To be accountable also means that one has to accept sanctions or retributions for not acting accountably. Many developed countries have a plethora of accountability mechanisms, either incorporated into the public service system, or specifically set up as independent agencies: Offices of ombudsmen/women, independent review boards, complaints commissions, etc. Their reach and effectiveness varies per country, but, in tandem with a free press, reviews by such agencies can have a serious impact.
In countries where few redress mechanisms exist, being able to sanction those who do not act in an accountable way, is arguably the most difficult part of accountability considerations. A recent trend in international development is to call for transparency and openness, but without the ability to sanction transgressors, what is the point of making available evidence of accountability failures? In his seminal paper on the
16 uncertain relationship between transparency and accountability, in which he argues that transparency does not always automatically lead to accountability, Jonathan Fox puts this bluntly: “Transparency mobilises the power of shame, yet the shameless may not be vulnerable to public exposure” (2007, p. 663).
When it comes to being able to sanction unaccountable acts, Mulgan (2000) argues that accountability necessarily implies power: only when the observer stands above the observed can we speak of accountability. While the principal-agent theory does not necessarily apply in cases where citizens hold service providers accountable, it does serve to illustrate why this is difficult to achieve. Principal-agent theory is based on the notion that when one person (the principal) contracts others (the agents) to carry out a certain task on his/her behalf, the principal is then faced with the challenge of having to ensure the agents carry out this task to the agreed standard. Principal-agent problems occur when the agents do not carry out the task accordingly (Booth 2012a, p. 9). The relationship between a single principal and a few agents is straightforward, but in a large government bureaucracy, principal-agent problems can be a considerable challenge. In many developing countries, where civil service salaries are low and there may be a lack of mid-level managers who can oversee a workforce effectively, it is very common that ‘the agent’ (the nurse, teacher, district roads authority clerk, etc.) choses to act unaccountably and decides to turn up for work when it suits, rather than when ‘the principle’ (an amorphous ministry in the capital city far away) wants him/her to arrive (Leruth and Paul 2006).
Accountability in the public service is a particularly complicated challenge (Batley
2004, Mookherjee 2001, Polidano 1999): when a nurse in a remote clinic repeatedly fails to turn up for work, how can citizens hold this nurse accountable? While public
17 service providers, such as the nurse, are in theory duty bound to serve the public, in practice, it is the bureaucracy that pays wages and has the duty to manage and oversee its staff. This oversight, however, is often less than optimal and there may be few ways in which citizens can report that the nurse is never there. It is believed that such problems are evidence of the symptomatic “failures in street-level institutions and governance”, i.e. the relationships of accountability at the provider level are dysfunctional (Björkman et al 2006, p. 1). Such failures are common, especially in developing countries, where staff shortages mean that quality control, oversight and staff management are often minimal, and where nepotism and political appointments make state bureaucracies places where jobs are not allocated on merit, and underperforming staff are rarely ever sacked (Devarajan et al 2013, pp. 23-24).
Having identified this problem as a key obstacle to achieving better social development outcomes in poor countries, the international development community sought ways in which citizens could be supported to hold bureaucracies and street- level service providers accountable. This is how social accountability came into being.
2.2.2 What is social accountability?
The interest in improving accountability within public service provision stems from a growing awareness that enhancing the quality of public services offered in developing countries is of crucial importance to these countries’ social development, but that achieving this is proving to be a huge challenge. Despite years of investment in public services by developing country governments and development agencies, it has become clear that the upgrading of infrastructure (such as schools, clinics and communications) can only improve public services to a certain level (World Bank 2004, Ringold et al 18
2011). Beyond this point, public sector policies and systems that provide sufficient
(and adequately trained) human resources and effective human resource management are the only way to further improve public service outcomes in, for example healthcare, education, or water and sanitation. (Chaudhury et al 2005, Dieleman et al
2006). Since the formulation of the Millennium Development Goals, in the year 2000,
United Nations agencies, bilateral and multilateral donors and non-governmental organisations have increased their focus on measurable development impacts (Barder
2012, Buntaine et al 2013) such as reduced mortality rates, literacy rates and school completion, and access to clean water. These development results, it has been shown, are predominantly linked to citizen’s access to quality public services (Travis et al
2004).
The World Bank report titled ‘Making Services Work for Poor People’ singled out
‘failures in accountability relationships’ as being at the heart of the problem when it comes to sub-standard public service provision:
For the services considered here - such as health, education, water, electricity, and sanitation - there is no direct accountability of the provider to the consumer. Why not? For various good reasons, society has decided that the service will be provided not through a market transaction but through the government taking responsibility. […] That is, through the “long route” of accountability - by clients as citizens influencing policymakers, and policymakers influencing providers. When the relationships along this long route break down, service delivery fails (absentee teachers, leaking water pipes) and human development outcomes are poor. (World Bank 2004, p. 6)
The same report goes on to suggest: “Given the difficulties in strengthening the long route of accountability, improving the short route - the client-provider relationship - deserves more consideration” (2004, p. 9). This call was answered with a groundswell of new initiatives designed to use clients’ social pressure to improve service providers’
19 accountability, to pressure states into becoming more transparent about their spending on public services, and tracing expenditure within the public sectors (Joshi 2010a).
Within this range of interventions, social accountability programmes are just one type of intervention that can be used to improve accountability in the public sector by applying social pressure. In recent years social accountability has grown from being identified as the actions of individuals and groups who combine “[…] information on rights and service delivery with collective action for change” (Aragwal et al 2009, p.
1), to a broadening of the definition to include a wider range of actors and issues which social accountability may engage with. Malena et al describe it as follows:
“Mechanisms of social accountability can be initiated and supported by the state, citizens or both, but very often they are demand driven and operate from the bottom up” (2004, p. 3). To what extent social accountability interventions are truly bottom up is somewhat debatable.
According to some academics, social accountability suffers from being perceived as too many things to too many people; as Joshi and Houtzager put it “there is little appreciation of what does not constitute social accountability” (2012, p. 151).
Houtzager and Joshi use a much narrower definition for social accountability: “the ongoing and collective efforts to hold public officials to account for the provision of public goods which are existing state obligations” (2008, p. 3). One detail is worth noting regarding these definitions: the vast majority of the literature on social accountability has been produced by only a few sources. The World Bank and associated academics are by far the largest contributors to the young but ever expanding body of work1, and beside this, there are two key British based sources: the
1 In particular the recently founded Global Partnership for Social Accountability, based at the World Bank: www.thegpsa.org. 20
Institute of Development Studies (IDS), associated with Sussex University, and the
Overseas Development Institute (ODI). What is striking about the two bodies of literature (grouping the UK-based ODI and IDS literature together for convenience), is that the World Bank literature tends to emphasise a more neo-liberal attitude towards public sector accountability (as evidenced by the definition used on page 20), often stressing the distorted nature of government supplied services, which do not react to market forces, while the IDS/ODI literature on social accountability tends to be more focused on rights. At implementation level the ideological differences are less noticeable. Service focused interventions have even seen something of an ideological convergence in recent years, with all the above mentioned institutions currently focusing on interventions that ‘work with the grain’ (Booth 2012b, Kelsall 2008, Levy
2014) or have the ‘best fit rather than best practice’ approach (Ramalingam et al 2014).
In the past decade, the use of social accountability has received unprecedented attention, reflecting the development community’s belief and investments in the methodologies. Which methodologies exactly, how they should be implemented and what terminology should be used to describe them, often remains unclear. The range of interventions that are loosely based around ‘accountability’, are often described with terms that are related, overlapping, and used interchangeably. There are, for example, several reports on accountability and service delivery that use the term ‘citizen voice and accountability’ (Rocha Menocal and Sharma 2008), or ‘citizen voice and state accountability’ (Tembo 2012), while a range of other reports opt for ‘transparency and accountability’ (Calland 2010, Joshi 2010a, 2010b, McGee and Gaventa 2010 and
McGee and Gaventa 2011). Yet others use ‘voice and accountability’ (Holland et al
2009) or ‘democratic accountability and service delivery’ (Mejia Acosta 2010). There are some reports that emphasise the role of citizens in the title, e.g. ‘mapping the 21 outcome of citizen engagement’ (Gaventa and Barrett 2010) or ‘civil society, civic action and accountability’ (Devarajan et al 2011). The large majority of the reports on the same topic, however, use the term ‘social accountability’ (Ackerman 2005b,
Claasen et al 2010, Clarke and Missingham 2009, McNeil and Mumvuma 2006,
Ringold et al 2011, Tembo 2013).
The majority of the above-mentioned works theorise about a wide range of accountability interventions, citing case studies that involve anything from community based audits of road quality (Olken 2009), to the effectiveness of an Ombudsman as a redress mechanism (Pienaar 1999), or the involvement of the media in education reform (Reinikka and Svensson 2011). These interventions clearly have quite distinct entry points. Much of the literature on social accountability can be subdivided into activities that work at three different levels:
I. National or regional level policy making and governance, such as Ombudsmen,
redress mechanisms or participatory budget projects, all of which work at the
higher levels of government, aiming to improve citizen’s access to and
influence over policy or budget decisions.
II. Straddling national and grassroots levels: local government-level participatory
planning or budget tracking projects which ensure that already committed
funds reach the intended destination and are spent on the designated goods or
services.
III. Grassroots level: Public service monitoring projects aim to improve the basic
public service delivery by engaging service users in audits, feedback or
dialogues with service providers, about the service they receive.
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A transparency and accountability family tree2 (figure 2) should help to illustrate how the social accountability as a methodology fits within a wider range of accountability interventions, and delineate the sub-section of social accountability on which this research is centred, namely the third category: interventions that aim to improve basic public services at community level.
Figure 2: The social accountability family tree
Transparency/accountability Usually pressure from in natural resource extraction activist groups with (or on behalf of) citizens who will Transparency/accountability benefit from a in donating and delivering reduced ‘leakage’ or foreign aid lack of power to Voice, decide how revenue is Open Government Initiatives: Transparency allocated transparency/accountability Participatory budgeting to ensure in government revenue and & that communities have a say in spending Accountability prioritising local authority spending on public services Social Accountability: Direct beneficiaries of public Budget tracking to ensure services or budgets put salaries + other funds get from pressure on service providers ministry to school or clinic to act more accountable Monitoring/auditing of public services (often using dialogue between service users and service providers) to ensure at least minimum quality health, education, water, etc. is delivered (free/at correct price)
From this point forward, when the term social accountability is used in this thesis, it shall mean the specific sub-section of social accountability interventions that focuses on basic public services at community level, unless otherwise stated.
2 Conceived and drawn by the author. It should be noted that certain interventions included in the social accountability family tree are also referred to by different names, such as participatory development or citizen-led planning. This diagram merely intends to clarify where this research sits in relation to similar development interventions, it does not provide a definitive set of classifications for the other types of interventions.
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2.2.3 Current academic debates within the social accountability literature
In recent years the focus has shifted and the current debates around social accountability are much more cognisant of the political implications these interventions can have. Because the literature on social accountability is fairly young, it was initially criticised for being self-referential and sometimes overly focused on methodology (Joshi and Houtzager 2012). Social accountability is often considered primarily a methodology, not a philosophy. Unlike concepts such as social capital or right-based approaches, which are often debated from a philosophical angle, social accountability is in some respects more like micro-finance, a methodology about which many debates revolve around ‘ways to do it’ rather than ‘why do it’.
While the practice of social accountability at times remains overly technically focused, the academic debate about the circumstances under which social accountability interventions succeed or fail has somewhat moved away from the technical. The term
“political economy” (Aksoy and Hoekman 2013, Devarajan et al 2013, Wild and
Harris 2011) is now central to the discussion. It has to be noted that terms such as ‘best fit’, ‘working with the grain’, and ‘political economy savvy solutions’ are used not only in the context of social accountability interventions but ever more frequently about the wider ‘good governance agenda’ within international development
(Carothers and de Gramont 2014).
According to the World Bank’s definition dating back to 1992, “[…] good governance is an essential complement to sound economic policies. Efficient and accountable management by the public sector and a predictable and transparent policy framework are critical to the efficiency of markets and governments, and hence to economic development” (The World Bank 1992, p. v). The early ‘good governance’ agenda has
24 been critiqued for its naiveté, trying to promote development by making developing country institutions just like those in the West (Crook and Booth 2011, Olivier de
Sardan 2011). Merilee Grindle’s suggestion that the international development community should move from a ‘good governance’ to a ‘good enough governance’ agenda (2004), was embraced by Rocha Menocal who argued that this should be done
“[…] based on a more instrumental, selective, and pragmatic understanding of governance […]” promoting governance reforms “in a more realistic way starting with where a particular country is” (2011, p. 15).
In more recent years it has become more common to question widely accepted development doctrines such as the good governance agenda, and the ways of working that go with it. The African Power and Politics Programme, for example, brought together researchers to look at ‘what works’, which resulted in an academic debate around the idea of ‘going with the grain’, about which it concluded:
At the national level, as at the sectoral and local levels, what works does not seem to be ‘good governance’ as is currently understood. Our comparative work on neo- patrimonial regimes shows very clearly that it is possible for a government to pursue successful developmental policies within a political system which operates primarily on the basis of patron–client relations and thus ‘goes with the grain’ of the dominant mode of state–society interaction. (Crook and Booth 2011, p. 100)
In such settings, ‘going with the grain’ implies limited or qualified acceptance of the existing framework of political relationships and identifying and exploiting creative possibilities within it.
Academics and development practitioners are becoming increasingly focused on the
‘political economy considerations’ that affect development interventions (Aksoy and
Hoekman 2013, Devarajan et al 2013, Blimpo et al 2013). Booth defines political economy as follows: 25
Bridging the traditional concerns of politics and economics, it focuses on how power and resources are distributed and contested in different contexts, and the implications for development outcomes. It gets beneath the formal structures to reveal the underlying interests, incentives and institutions that enable or frustrate change. Such insights are important if we are to advance challenging agendas around governance, economic growth and service delivery, which experience has shown do not lend themselves to technical solutions alone. (Booth et al 2009, p. 1)
Social accountability interventions do not escape political economy problems, which are now acknowledged as serious obstacles to the success of such interventions.
Devarajan observes: “[…] ignoring the underlying political economy drivers of accountability may have been a principal factor accounting for cases where results [of social accountability interventions] were less than satisfactory” (Devarajan et al 2013, p. 31). And equally, within the implementation of social accountability interventions,
Tembo writes about the recruitment of ‘contributors’ who can play a role in social accountability interventions “[…] always bearing in mind that the contributors will also have self-serving incentives and interests” (Tembo 2013, p. viii). It is therefore not surprising that the latest trend in social accountability encompasses a shift from
‘best practice’ to ‘best fit’ (Levy 2014, Fox 2014). Commentators are increasingly talking about ‘strategic social accountability’ (Poli and Guerzovich 2014), evolved types of interventions that are politically savvy, or pragmatic, cognisant of the power dynamics in the area where they operate, and aware of the political economy implications of their interventions. While such ‘ideal type scenario’ debates may be asking for more than can be realistically achieved, it proves that the social accountability literature has matured and is evolving.
While academics drive the debate on strategic social accountability (Fox 2014), they are in danger of leaving practitioners behind, just like a decade ago, when the earliest papers on social accountability became so technical that they lost their relevance for 26 those who were tasked with implementation. That gap continues to exist, as the academic debate becomes increasingly focused on finding the ‘right fit to match the local context’, practitioners aren’t always up to date with the latest ‘best practice’, as evidenced in this comment by a social accountability expert tasked with evaluating funding applications for social accountability interventions:
While many applications attempt to target specific problems, in many cases both the policy and political analyses are limited. In turn, the strategies that applicants proposed failed to take full advantage of the local political context in which they operate, overlooked ongoing sector reforms and incentives of key decision makers or threatening vested interests, and ignored the fact that many factors that shape social accountability chains are outside of their immediate control.
(Guerzovich and Poli 2014, p. 3)
A contributing factor to this continued schism between the policy debate and practice is that the academic and policy dialogue around social accountability at higher level is now almost exclusively focused on the political, the strategic, the ‘right fit’. While this trend is a very useful antidote to the previous state of social accountability literature - which took too little account of the environment in which an intervention was to be implemented - some caution is needed. Current social accountability policy debates largely takes place within the walls of the World Bank in Washington DC, within a select few academic institutions or at best at international NGO’s head offices. As a result, its details rarely reach the practitioners who implement these programmes in the field.
2.2.4 Gaps in the social accountability literature
There are a number of clear gaps in the literature on social accountability interventions. There is little research that compares several social accountability 27 interventions within the same country, or with a clear focus on a single sector. The majority of the studies review either a single case, or compare a wide range of interventions which have little in common methodologically or in terms of sectoral focus (Devarajan et al 2013, Gaventa and Barrett 2010, Joshi 2010b, McGee and
Gaventa 2011, McGee and Gaventa 2010, Rocha Menocal and Sharma 2008, Tembo
2012, Tembo 2013). This tendency to go for broad spectrum reviews, or otherwise focus on one single intervention, leaves the reader without an opportunity to compare like-with-like, get a sense of methodological differences or the efficacy of an intervention when applied in a certain sector.
Secondly, with the exception of a handful of reports (for example Björkman and
Svensson 2007, Shah 2003, Tembo 2013), the majority of social accountability- focused are written as desk reviews. Desk studies have significant drawbacks: they are often based on NGO project reports which focus on results, not process. Valuable details about the interventions are often missed out, leaving researchers guessing about causality. (McGee and Gaventa 2010, pp. 8-13, Gaventa and Barrett 2010, pp. 14-16).
Many such papers expose the design flaws in social accountability interventions: some lack well-developed theories of change, others are based primarily on the assumption that greater transparency automatically leads to greater accountability (Fox, 2007,
O’Neil et al, 2007, Joshi 2010b). Notable is the fact that many articles in this category draw the same conclusion, believing that it is impossible to state that social accountability interventions always work. Most papers include examples of proven success and relative failure, often ending articles with the advice that more research is needed (Ringold et al 2011, pp. 91-101, Rocha Menocal and Sharma 2008, pp. 19-31,
Gaventa and Barrett 2010, pp. 12-16).
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Thirdly, much of the literature on social accountability targeting basic public service provision is based on interventions that were implemented in the Indian subcontinent
(Banerjee et al 2010, George 2003, Hossain 2009, Khemani 2007) or on a handful of relatively stable African states such as Uganda, Malawi, Kenya, Zambia and Ghana
(Deininger and Mpuga 2005, Foresti et al 2007, Gaventa and Barrett 2010, Wild and
Harris 2012). In 2012, when this research started, social accountability interventions were rarely implemented in fragile or conflict affected states. While several have been published since, there is still a dearth of information about what works in such settings.3
This research aims to contribute to filling these gaps, by focusing on empirical research conducted in Sierra Leone. Comparing four social accountability interventions that targeted one of the world’s worst performing health sectors (Sierra
Leone has the lowest life expectancy in the world, according to the 2014 Human
Development Index), this study provides a unique opportunity to examine the efficacy of social accountability methodologies under challenging circumstances.
2.2.5 Criticism of social accountability methodology
Social accountability methodology has its detractors. The notion of social accountability as a methodology to improve frontline public services has been criticised as a neo-liberal tool to co-opt communities into monitoring frontline services provided by a small state that does not allocate sufficient resources to provide adequate
3 Recent publications include Tembo’s 2013 review of the Mwananchi programme – implemented in Sierra Leone, as well as Ghana, Kenya, Malawi, Uganda, and Zambia; the Tuungane programme in the Eastern DRC, described in detail by Ho et al 2015, McGee and Kroesschel’s review of TAIs in Bangladesh, Mozambique and Nepal.
29 checks and balances to ensure a minimum standard of basic public service provision
(Bazbauers 2012). The neo-liberal narrative would construe the aim of providing better services as predominantly a tool for increasing productivity and economic growth
(Acemoglu et al 2005). Social accountability methodology relies heavily on citizen participation. As with all participatory development programmes, when a programme is not implemented well and yield few results, it risks being criticized for taking up people’s valuable time. Even though many citizen participation interventions achieve results that are well worth the time invested in it, it should never be overlooked that poor people often face substantial time constraints, and that it is not always in their interest to participate in development interventions (Cleaver 2001, p. 51, Mayoux
1995, p. 241).
However, social accountability interventions have largely been perceived as positive tools that can be used to assist communities to claim their rights to a minimum standard of healthcare, education, and other services. The idea of economic growth as a primary objective for the delivery of public services has largely been supplanted by the notion that access to basic services is a human right (Eyben, 2003, Miller et al,
2005). Rights-based thinking underpins much of the literature on social accountability;
Houtzager and Joshi, for example talk about public services as existing state obligations (2008, p. 3, see also Ackerman 2005a).
It is clear that social accountability interventions operate in an environment constrained by the geopolitical realities faced by the majority of developing countries.
The pressure on public service staff to perform better would not be as great if developing countries were able to recruit at least the recommended minimum number of nurses and teachers and other vital frontline service deliverers (these are described
30 in the ‘Abuja targets’4). This is not always possible, because of the limits on public sector wage bills, imposed on many heavily indebted countries by international lending institutions such as the IMF (McCoy et al 2008, Hanlon 2005). These limits are often practical and necessary, but they can at times be overly stringent or continued for longer than needed, limiting basic service provision. These facts often go unmentioned in the social accountability literature.
2.2.6 Isolating recurring themes from the social accountability literature
From the general review of the social accountability literature it is possible to isolate three recurring themes which are common in most interventions, these are redressing information imbalances, citizenship and participation, and power and politics.
1) Redressing information imbalances
Closely related to social accountability, especially in practical terms, is providing citizens with better access to information. Schleder notes, about accountability, “… [it] thus involves the right to receive information and the corresponding obligation to release all necessary details” (1997, pp. 2-3). Social accountability interventions usually start by tackling, what Vian calls “imbalances of information” (2007, p. 84).
Agarwal et al (2009) note in their definition of social accountability that providing citizens with information about services and their entitlements is central to the methodology.
4 http://www.uneca.org/adf2000/abuja%20declaration.htm, signatory governments agreed to strive to spend 15% of the national budget on the health sector. 31
Providing citizens with useful and relevant information regarding the services they are entitled to, is an important component to allow individuals or groups to take the first steps towards holding service providers accountable (Brinkerhoff and Azfar 2006, p.
6). Joshi argues: “The logical chain linking transparency to empowerment is clear: information is power. When better information about rights and processes is disseminated, awareness about entitlements is likely to increase” (2010, pp. 8-9).
When, for example, absenteeism in public services is a problem (and it is in so many developing country schools and health facilities, e.g. Bruns et al 2011, Chaudhury et al
2005, Leonard et al 2007, McPake et al 1999, Van Lerberghe et al 2002) providing patients or parents of school-going children with details about how many full time employees there ought to be at their local school or clinic, enables service users to apply social pressure by questioning staff’s absence. The role of information is often that of a catalyst; if entitlements are not commonly known about, the demand for services can be low, as people simply consider certain services beyond their reach.
Once it becomes clear that people have the right to a certain service (or to a certain standard of service), the lack of it often becomes more acutely felt.
A well-known randomised controlled trial involving social accountability, conducted in Uganda, compared 25 control clinics, where no intervention took place, to 25 communities in which community monitoring with citizen report cards was used to improve primary healthcare services (this is where a range of information was provided to citizens). Service users who used the ‘treatment clinics’ were provided with information about entitlements and staff arrangements, plus details on how well their local school or clinic performed in relation to other facilities nearby (Björkman and Svensson 2007, pp. 8-10). The purpose of including this information was to allow
32 citizens to develop a sense of indignation if their nearest facility underperformed in comparison to others in the locality (tangible comparators). This particular trial was a great success, but its follow-up study, in which the information element was left out, provided the more striking results: when the experiment was extended to another 25 health facilities using a Community Driven Development approach (which is similar to the citizen report card and community monitoring in its participatory approach), this method was proven less effective because it lacked one key ingredient: “access to reliable and structured information on the community’s entitlements and the status of service delivery” (2007, p. 3). The study concluded that “enhanced participation alone
[…] has little impact without changing the existing informational asymmetries”
(Björkman-Nyqvist et al 2011, p. 5).
Expectations regarding the promise of redressing information imbalances should however remain realistic. Providing information alone does not always spur individuals on to act. Lieberman et al provide an interesting analysis as to why an intervention in Kenya that focused on providing parents with information regarding their children’s educational attainment seemed to have had close to negligible impact.
Additional information provided by the project focused on how parents could help their children to improve their learning (privately) and how they could get engaged to advocate for better education standards (collectively). The authors provide the following observation regarding information-based interventions:
Specifically, we argue that for information to generate citizen action it must be understood; it must be new; it must cause people to update their priorities; and it must speak to an issue that people care about and feel it is their responsibility to address. In addition, the people at whom the information is directed must possess the skills and knowledge to know what to do in light of the information; they must have the efficacy to believe that their actions will generate results; and, to the extent that the outcome in question requires collective action, they must believe that others in the community will
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act as well. The absence of any of these conditions may be enough to interrupt the link between information and behavioural change. (Lieberman et al 2012, pp. 3-4)
It is clear from many other empirical studies, especially those related to information and voting behaviour (Banerjee et al 2011, Pande 2011) that the provision of information alone does not always change behaviour. In addition to the many conditions Lieberman and colleagues observe, the issue of power should not be overlooked. Challenging service providers on which citizens have to rely for their healthcare and their children’s education carries a huge risk. While several social accountability papers stress the empowering nature of choosing an alternative provider
(‘Voice and Exit’ see e.g. Brinkerhoff et al 2012), this is only an option in densely populated areas where there is a choice of providers; for many inhabitants of rural
Africa in particular, an alternative provider is usually located too far away, which gives the few available government providers undue power over the community that relies on them for vital service delivery.
While more research is needed into the circumstances under which citizens are spurred into action, evidence suggests that the shape in which information is presented can contribute to the likelihood of a positive response. In a developing country context, high illiteracy rates are common, which means that certain people may have difficulties grasping basic information such as percentages. Online information is obviously only accessible to individuals who own internet enabled devices and live in areas where internet connections are available – while these are on the increase, there are still many developing countries where internet access is below 10% of the population (World Bank 2015).
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2) Citizen participation
In the context of service delivery, accountability can be exerted top-down, from higher-level officials; sideways through competition or peer pressure from other providers; externally by international or multilateral organisations, and other outside actors; and bottom-up by citizens, CSOs, NGOs, and the media (Ackerman 2005, Joshi
2010a, 2010b).
For a person to be able to hold service providers to account, an individual first needs to feel entitled to the service. Accessing or trying to utilise public services are all part of what it means to be a citizen. The notion of citizenship is important for individuals who are invited to discuss their grievances regarding access to quality public services through social accountability mechanisms (Ringold et al 2011, p. 13). This is especially true in fragile states, where individuals may not always identify themselves as rights-holding ‘citizens’ nor are all inhabitants always treated as such by the authorities. “The mutually constitutive nature of the state-citizen relationship, and the extent to which different kinds of states make different kinds of citizenships possible, is something that is curiously muted in prevailing governance discourses in development”, write Cornwall, Robins and Von Lieres (2011, p. 7). This is also true for social accountability literature, very little is written about attempts to solicit citizen engagement in areas where citizens contest the legitimacy of the ruling government.
Interestingly, several social accountability interventions have been found to contribute to people’s increased sense of citizenship (Benequista 2011, pp. 5-6, Walker 2009, pp.
1043-46). In a meta review of 100 citizen engagement interventions - many of which were social accountability interventions - Gaventa and Barrett analysed the impact that these projects had. The review revealed that 80 percent of the interventions achieved
35 positive improvements on ‘the construction of citizenship’ component: “Through knowledge, awareness and increased confidence comes an overall identity of citizenship, or the belief in one’s right and ability to participate. This step from silence to citizenship is not taken in one leap, but it is often an iterative process […]” (2010, p.
30).
An understanding of the nature of citizenship is also of crucial importance when interventions need the active participation of citizens. One definition of active citizenship is as follows:
[… a] combination of rights and obligations that link individuals to the state, including paying taxes, obeying laws, and exercising the full range of political, civil, and social rights. Active citizens use those rights to improve the quality of political or civic life, through involvement in the formal economy or formal politics, or through the sort of collective action that historically has allowed poor and excluded groups to make their voices heard. (Clarke and Missingham 2009)
Social accountability interventions cannot be implemented without some element of participation of citizens, communities, and individuals who are entitled to basic public services. Ideally, accountability interventions should be initiated by citizens, if and when they feel the need to address service delivery shortcomings. The reality is that most social accountability interventions are implemented on their behalf. However, they cannot be successful if citizens aren’t able and willing to participate and are central to the intervention.
In the past three decades, participatory development has been both lauded by some as the “new paradigm” for development (Chambers 1997) and criticised for all too often being empty rhetoric, a tick box exercise or worse (Banerjee et al 2010, Cooke and
Kothari 2001, Parfitt 2004, Shahrokh and Wheeler 2014). Cleaver berates development
36 practitioners for failing to seek a more “dynamic vision of ‘community’ and
‘institution’ that incorporates social networks and recognises dispersed and contingent power relations, and the exclusionary as well as the inclusionary nature of participation” (1999, p. 609). Cleaver sums up some of the many pitfalls of participation; it is often implemented in a tokenistic way, sometimes interventions are started hurriedly without getting to know a community, or participation can end up being more like coercion. Too often NGO staff are so convinced of their project’s value to an entire group, that they never stop to think if participation might be the best use of time for a poor, time-constrained individual (Mayoux 1995).
Over the years, many studies have confirmed that participatory projects can be vulnerable to ‘elite capture’ and that current efforts to mitigate the opportunism of local leaders are not always sufficient (Green 2000, Platteau 2004). Some participatory development interventions have been criticised for their fundamental assumptions, particularly their idealised understanding of community. By characterising urban and rural ‘communities’ as cohesive and, for the most part, homogenous and harmonious entities, community-based approaches can at times be based on a lack of understanding of the context within which participatory projects take place (Cornwall 2002, Mohan and Stokke 2000). In social accountability interventions it is important that such glossing over the reality does not obscure both local and wider structures of power that often prevail, as they can undermine an interventions’ success from the start. In interventions where participation is tokenistic and fails to take account of the target community’s diversity, social accountability interventions often fail to achieve sustainable improvements in service delivery for the wider community or further transformation of the ‘unequal access to services’- status quo.
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It has to be noted that not all accountability interventions aim to achieve long lasting transformations. McGee and Gaventa warn that too many transparency and accountability interventions “focus on the delivery of development outcomes narrowly conceived, neglecting or articulating only superficially the potential for deepening democracy or empowering citizens […]” (2011, p. 8).
Citizen participation cannot be fully explored without highlighting ‘collective action problems’ which have only in recent years begun to attract more attention. Booth defines the issue as follows:
A collective action problem exists where a group or category of actors fail to cooperate to achieve an objective they agree on because the first movers would incur risks and they have no assurance that the other beneficiaries will compensate them, rather than ‘free riding’. The problem is more likely to arise when the group in question is large and the potential benefits are widely shared (non-excludable). Solutions to collective action problems involve enforcing rules (‘institutions’) to restrict free riding and thereby motivate actors to act in the collective interest. (Booth 2012a, p. 11)
Collective action problems can be a major obstacle to citizen groups becoming actively involved in the ‘holding to account’ of their local service provider. Especially when such collective actions carry retaliatory risks and there is no guarantee that efforts will lead to improvements, it is, understandably, difficult though necessary, to motivate individuals to engage.
3) Power and political awareness
Power and political awareness are undeniably part of social accountability interventions; however, it is only more recently being acknowledged that these concepts are central to social accountability interventions (Cornwall and Leach 2010,
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Joshi and Schultze-Kraft 2014). A critique of participatory methodologies, and also of some social accountability interventions, is that the focus on getting the technique right often undermines the awareness about the politics of participation, as White states
“Sharing through participation does not necessarily means sharing in power” (1996, p.
6). Such critiques were voiced when social accountability methodologies started to become more widely used; some critics argued that focussing on getting the tools right takes away the emphasis on the fact that extracting accountability and reducing disempowerment are inherently political acts (Joshi and Houtzager, 2012). The issue of power lies at the heart of participatory development, and indeed social accountability
(Rocha Menocal 2014, Wild and Foresti 2013). Both are essentially tools to tackle the power imbalance that keeps certain citizens poor and prevents them from claiming their rights (Hughes et al 2005).
The tendency to opt for methodological solutions to inherently political problems and aim for ideal type solutions which are copied from developed countries is what
Carothers and de Gramont call “the temptation of the technical”:
[…] the belief that they could help economically transform poor countries by providing timely doses of capital and technical knowledge while maintaining a comfortably clinical distance from these countries’ internal political life. These views took hold strongly in those early years, exerted a powerful influence throughout the intervening decades, and are still prevalent in the development aid community today. (Carothers and de Gramont 2014, p. 3)
Since 2010, the emphasis has shifted somewhat and there is now a much greater acknowledgement of the politics that are involved in the use of social pressure to improve basic service delivery. Poli and Guerzovich suggest:
[…] we have learnt why so many projects fail: Social accountability’s promises have not been fulfilled, in large part, because the technical tools we have been using do not take account of the political nature of accountability processes. Holding public
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officials accountable is a contested and uncertain process, and therefore ignoring public officials’ incentives pose large risks to the success of a social accountability project. (Poli and Guerzovich 2014)
Devarajan et al introduce the notion of “political economy drivers of accountability” arguing that “important domain for improving accountability is through the political relations between citizens, civil society, and state leadership” (2011, p. i). The same paper further warns about the over-optimism regarding citizen engagement:
However, strategies and interventions in this regard need to be cognizant of underlying political economy drivers of failures in accountability. In political economy environments characterized by high degrees of clientelism and rent-seeking, such as are widespread in the Africa region, an unqualified faith in civil society as a force for good is more likely to be misplaced. (Devarajan et al 2011, p. 7)
Devarajan et al (2011) further point out that civil society’s effectiveness will always be constrained by existing incentive/sanctioning mechanisms within the state, be they formal judiciary, auditing departments or other sector specific oversight instruments.
The effectiveness of a social accountability intervention is therefore contingent on its alignment with broader political strategies, and underlying structures of power in a society.
The practical guidance for those who implement social accountability interventions has taken a long time to catch up with the focus on power and politics. The complete absence of the word ‘power’ in some of the most readily available social accountability toolkits, guidelines and how-to notes confirms that the ‘grey literature’ of handbooks and manuals (Addai 2004, Claasen et al 2010, Pekkonen no date, Post et al no date,
Shah 2003, Singh and Shah no date), shows that a significant lag exists between the academic debate and guidance provided to those who implement social accountability
40 interventions. Several more recent guidance notes on social accountability or citizen engagement have been more power aware in nature.5 These papers seem to acknowledge the existing gap in guidance for practitioners, especially on ‘being cognisant of context’, ‘being power aware’ or ‘devising multi-pronged social accountability strategies’ all of which are recent themes that academics believe can have a positive impact on a social accountability intervention’s success.
The interrelatedness of the three themes – redressing information imbalances; citizen participation; and power and political awareness, cannot be emphasised strongly enough: providing individuals with information is often a first step on the road towards greater empowerment in which service providers no longer hold the ‘power of information’ over the ordinary service user. As stressed before, participating in accountability interventions can have a profoundly transformative effect on people’s lives; it can enhance their sense of citizenship and empower them to challenge existing power relations.
Before this chapter concludes, I will briefly examine two further literatures, namely corruption literature and the literature on human resources for health. Both literatures inform this research by providing a historical appreciation of the problem of corruption, specifically in a low income country setting, and a deeper understanding of the ‘healthcare in developing countries’ context in which the empirical research on social accountability interventions for this thesis took place.
5 A Working Paper Series by World Bank/Kenya School of Government, Centre for Devolution Studies, Working Paper Series consisting of six papers: Finch and Omolo 2015a, 2015b, Machira and Nizam 2015, Nizam and Rugo 2015a, 2015b, and, Omolo and Nizam 2015. The Global Partnership for Social Accountability has been publishing a series of ‘learning notes’ that can be accessed at: http://www.thegpsa.org/sa/resources. 41
2.3 Social accountability and corruption literature
The following section focuses on those aspects of the corruption literature that are relevant to social accountability. As this is one of two secondary literatures, this segment is only a brief description of some of the key texts and issues that are worth highlighting in relation to this research.
2.3.1 The differences between corruption and social accountability literatures
Despite the obvious overlap between the two disciplines, it is striking to find a general avoidance of the term corruption in the social accountability literature. It is clear that the ‘lack of accountability’ that social accountability interventions aim to improve upon so often manifests itself as corruption. Joshi’s mention of corruption in a paper on social accountability is one of the few exceptions:
Despite demands for accountability and exposure of corruption, experience suggests that the kinds of direct social accountability mechanisms discussed above, have little traction unless they are able to trigger traditional accountability (e.g. investigations into corruption) and impose formal sanctions (fines for delays in provision of services). (Joshi 2010a, p. 10)
The social accountability literature is not the only literature where this avoidance of the word corruption is evident. McPake et al, writing on issues related to human resources in the health sector deplores the same trend in the literature on health:
The shying away from terms such as corruption or bribery undermine the awareness that the issues at stake are serious, and in the health sector can be life threatening, as absenteeism, unresponsiveness, theft of medical supplies and the informal changing effectively denies the poor access to basic services. (McPake et al 1999)
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The social accountability literature uses terms such as ‘elite capture’ or ‘lack of accountability’.6 The differences in terminology signal a clear distinction in how both disciplines approach the issue. The corruption literature focuses strongly on the offence, its consequences and how this can be prevented. The social accountability literature, on the other hand, often treats corruption as a given: elite capture and political economy considerations undermine service delivery. Within corruption literature it seems that the ‘why’ question barely gets a mention, while in the social accountability literature the ‘what’ question (what gets taken, by whom and how) is all too often glossed over.
One of the notable exceptions within the social accountability literature is a paper by
Devarajan et al, which explains the ‘what’, ‘why’ and gives an example of ‘how’ in much greater detail than is usually the case:
In the African context, both rent-sharing among elite groups and clientelism are often linked to identity-based groups, of ethnicity, religion or region […] Bureaucracies and other un-elected positions are in most Sub-Saharan Africa thoroughly embedded in political and social relations […] Where bureaucratic, judicial and other “compact” positions are allocated as a form of patronage (to family, friends or co-ethnics, etc.), the incentive structure is intrinsically about the reciprocal provision of political loyalty, as opposed to delivery of service. This is consistent with the malady of low effort, such as teacher absenteeism […]. (Devarajan et al 2011, pp. 10-11)
There are some important lessons that practitioners of social accountability can learn from the corruption literature. Robert Klitgaard developed a universal formula for the possible occurrence of corruption. He democratised the incidence of thefts, graft and venality, arguing that corruption can exist anywhere, under certain circumstances, using the following equation (1998):
6 These terms are also common in the participatory development literature and the literature on public policy. 43
Corruption = Monopoly + Discretion – Accountability
Klitgaard argues that “one will tend to find corruption when somebody has a monopoly on power over a good or service, has the discretion to decide whether or not you receive it and how much you get, and is not accountable” (1997, p. 501).
Klitgaard’s description helps to explain the challenges of many developing countries’ public services: a public sector nurse or teacher in a rural facility has a monopoly over the provision of healthcare or education, the discretion to decide whom to provide it to, while very weak accountability systems are in place to keep their power in check. In order to examine how this problem can be solved, it is important to ask why this remains so.
While most of the corruption literature has focused on how corruption manifests itself and what impact it has on a country’s economy, in recent years a new body of corruption-related literature has developed which also looks at the “why?” Research into the political economy of corruption delves deeper into the reasons why certain countries have high levels of corruption. High level corruption deprives the exchequer of funds that could be used to pay decent public sector wages and ensure that the civil service has sufficient and transparent oversight mechanisms, without which petty corruption becomes much more likely – in many cases we can therefore consider it a
‘vicious circle’ problem; it takes significant effort (as well as political will and courage) to break out of this circle. High levels of corruption can also be a function of the undemocratic state, which exploits the economic uncertainties of a corrupt system to buy patronage that keeps a despotic regime in power (Dutta 2009, Jain 2001, Rose-
Ackerman 1996, Wedeman 1997). Many of these papers describe how imbalances in
44 the distribution of power within the political economy can supply an incentive structure that makes corruption more likely to occur.
2.3.2 Corruption in the health sector
In order to reach a better understanding of the specific problems within the public sector, it is necessary to examine a small sub-section of the corruption literature devoted to corruption in the public service sectors. For this research, I briefly examine the health sector related corruption literature.
The health sector is uniquely vulnerable to corruption for several reasons: the demand for health services is uncertain and hard to predict; there are many different actors involved, ranging from ministry of health and government officials at regional and local levels to care providers, regulators, providers of medical supplies, insurance companies, hospital management, private clinics and of course, patients (Savedoff and
Hussmann 2006, Savedoff 2011). In developing countries, where staff shortages make management and oversight even more complicated (Reynolds et al 2008, Trap et al
2001), curbing corruption is a serious challenge (McPake et al 1999, Stringhini et al
2009). Vian (2007) believes a high degree of imbalances of information and an inelastic demand for services are the root cause of corruption within the health sector in developing countries. A UNDP reported noted that “[…health services are] highly decentralised and individualised making it difficult to standardise and monitor service provision and procurement. Limited regulatory capacity in many developing countries adds to the problem” (2003, p 113). Savedoff and Hussmann argue, in many developing countries (and many developed ones too) health professionals have assumed a cultural role as trusted healers who are above suspicion (2006). 45
Lewis’ writing on governance and corruption in public health care systems (2006) reviews a range of studies in which evidence is provided of the link between a country’s governance and health outcomes, especially maternal, infant and under-five mortality. The paper concludes:
The review of country evidence and the examination of the cross-country factors that influence performance (and to some extent outcomes) in health care suggest that governance plays an important role. If the health system is not governed well, health workers are absent, patients pay illegal fees, and basic inputs are stolen without any consequences for those who mismanage or corrupt the system, performance of health services will be poor and population health will suffer. (Lewis 2006, p. 44)
Lewis argues that “government effectiveness, corruption and accountability” are best analysed together, “given the fact that all three elements are intertwined”. She asks: “Is poor service a function of corruption or simply mismanagement?” (2006, p. 13). This is a crucial issue that not many texts highlight. In reality, it is probably impossible to disentangle which problem contributes most to a badly performing health sector, and it is therefore a very valid suggestion to jointly assess these issues. What Lewis also highlights is the important fact that “better accountability can address both” (2006, p.
13), because when staff are held accountable for providing a decent level of service, neither corruption or mismanagement is tolerated. Hussmann makes some useful observations about difficulties in defining what can be truly classified as malpractice and what cannot:
While certain forms of grand corruption may be more universally considered criminal/unethical, the often blurred lines between gifts, socially accepted favours and bribes, and other historical and social factors make it hard to define other forms of corruption across nations. Even within a given country, not everyone will agree on the nature of corruption.
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Whilst most people would agree corruption is ‘wrong,’ it is not always illegal. For example, some countries tightly regulate physician conflict of interest in ownership of medical ancillary services, whereas other countries do not. (Hussmann 2011, p. 7)
Heidenheimer describes a range of malpractices as “black, grey or white corruption”, explaining how certain practices would be condoned by the majority in a certain community but not by another, depending on the type of informal system of governance that exists - these range from traditional kinship based systems to modern civic-culture based systems (2003, pp. 152-153).
To further understand these intricacies it is important to look in greater detail at sector specific literature. Only by gaining a profound understanding of some of the underlying problems in the health sector and the coping mechanisms that are employed to deal with such issues, social accountability practitioners will be able to design programmes that respond to the unique problems that prevail in a resource-poor medical sector. The next section of this chapter focuses on the human resources for health literature, which provides this research with greater insights into the realities faced by one specific group of frontline service providers: health workers.
2.4 Human resources for health literature
It is evident that the human resources for health literature deals with many problems that are similar to the social accountability literature, only it often approaches the issues from a different angle. In the human resources for health literature, topics such as understaffing, absenteeism, staff motivation, corruption and the stealing of medical supplies are common (Dieleman et al 2006, Ferrinho and Lerberghe 1999, McPake et 47 al 1999, Savedoff 2011, Serneels and Lievens 2008b). Much can be learnt from this literature, especially regarding the question of why health sector social accountability interventions succeed or fail.
In contrast to the literature on social accountability, which is remarkably quiet about what actual problems it aims to address, and how a lack of accountability within the public service might manifest itself, the literature on human resources for health does elaborate on these problems to a much greater extent.
McPake et al (1999) carried out a thorough analysis of all types of malpractice in a small number of Ugandan health facilities and found a median drug leakage rate of
76%, widespread staff absenteeism and informal charging, leading to a gross under- utilisation of the public facilities studied. Manzi et al (2012) found that 44% of the medical staff employed in the Tanzanian health centres they studied were absent in the period of their study, while only 14% of the recommended number of nurses were actually employed at these facilities. Stringhini et al (2009) finds the levying of informal charges for health services common among the several dozens of health professionals interviewed in a different part of Tanzania. Analyses of the compounding effects of absenteeism, the stealing of drugs and informal charging (Brinkerhoff 2004,
McPake et al 1999, Vian 2007) conclude that the combination of these malpractices effectively denies the poor access to quality healthcare, as McPake et al note: “Access cannot be considered to exist if a unit is nearby and open but there are no drugs or qualified staff present” (1999, p. 856). In all these cases it was often the research that provided the trigger that led to changes in policy. Having evidence about which problems were most common (absenteeism, charging or the sale of free medicine to private pharmacies) allowed policy makers to address the most serious issue first.
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Social accountability practitioners do not always have such detailed problem analyses available to them and often design programmes based on generic service delivery failures, at times missing opportunities to take a strategic approach that combines accountability improvements with lobbying for policy changes. Not having enough information about the operational environment in which social accountability interventions are implemented means that it is harder for programme designers to come up with a ‘good fit’ social accountability intervention model that takes account of this context and can respond to it.
While corruption-focused health sector literature’s depictions of the abuses of power by public healthcare staff are an important reminder of the realities facing those who implement social accountability interventions, these studies, at times, fail to tell the healthcare staff’s side of the story, portraying them primarily as predatory and corrupt.
Other human resources for health literature helps readers appreciate the challenging circumstances the majority of developing country healthcare workers operate in. Low motivation is often related to inadequate salaries (which are sometimes paid late or at a level that cannot provide for a decent standard of living) and to have few opportunities for promotion, further study, or professional development (Barr et al 2004, Mathauer and Imhoff 2006, Stringhini et al 2009, Van Lerberghe et al 2002). Despite an increased focus on the improvement of healthcare results, few programmes invest in structural changes in health systems that could improve on human resource management, providing better staff oversight, feedback, or recognition that could give encouragement for the job that health workers carry out (Ferrinho and Lerberghe 1999,
Franco et al 2001, 2002b).
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2.4.1 Staff motivation as a tool to encourage greater accountability
Compared to the social accountability literature, human resources for health literature goes into much more detail about (non-financial) incentives and management tools which can be harnessed to promote accountable behaviour (Adams and Hicks 2000,
Akintola 2010, Bhattacharyya et al No date, Mathauer and Imhoff 2006). In the past decade, the literature on health and human resources has started to focus on health worker motivation as one of the main contributing factors determining the quality of healthcare delivery in developing countries7. Motivation in the work place can be defined as “an individual’s degree of willingness to exert and maintain effort towards organisational goals” (Franco et al 2002a, p. 1255). Most studies make a distinction between two different aspects of internal motivation. Kanfer calls them ‘can do measures’ that influence worker-organisation goal congruence, and ‘will do measures’, that are directed towards goal striving. Dieleman et al make the same distinction, but express it in a simpler way: there is ‘the motivation to be in a job’, and there is ‘the motivation to perform’.
Academics describe ‘intrinsic motivation’ as an emotion or drive that individuals have within themselves. In a work context, it is highly influenced by internal and external factors that impact upon the job. Frey and Jegen (2001) posit that, contrary to our expectations, “external intervention via monetary incentives or punishments may undermine, and under different identifiable conditions strengthen intrinsic motivation”
(2001, p. 589). Their motivation crowding theory is based on research that was started by Titmuss in 1970, who discovered that paying for blood donations undermined the
7 See for example: Adams and Hicks 2000, Dieleman et al 2006, Franco et al 2000, Franco et al 2001, Franco et al 2002b, Leonard et al 2007, Manongi et al 2006, Mbindyo et al 2009a, Mbindyo et al 2009b, Paul 2009, Serneels and Lievens 2008a, Stringhini et al 2009. 50 social values related to donating blood for free, and as a result, reduced the willingness to give blood.
Mathauer and Imhof note that few authors mention “the cross impact of the will-do and can-do components” (Mathauer and Imhoff 2006, p. 3). One example is the connections between supervision and recognition. Several articles (Paul 2009,
Mathauer and Imhoff 2006, Dieleman et al 2006, Manongi et al 2006) make the point that supervision can be an effective management tool if it is used as a vehicle for recognition and positive reinforcement, but will be a less effective motivational tool if supervision is only used to critique.
Paul’s (2009) study of the effects of the introduction of performance-based pay in hospitals in Rwanda found significant evidence that improved staff motivation was not only linked to the financial incentives but also to the increased levels of monitoring, which provided the opportunity for praise and constructive feedback to the healthcare staff, crowding in, as motivational theorists would argue, intrinsic motivation.
Mathauer and Imhoff’s research paper discusses supervision in the workplace in Benin and Kenya. Its respondents also highlight the fact that supervision can be supportive and motivating, or, interpreted by others, also controlling or discouraging (2006, p. 9).
If monitoring can affect healthcare staff’s motivation positively or negatively, it highlights the need for a deeper understanding of the positive and negative triggers that should be incorporated or avoided, when monitoring or social accountability programmes are designed.
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2.4.1 The Millennium Development Goals – help or hindrance?
It is sometimes argued that the focus on the quality of service delivery would never have emerged if it hadn’t been for the Millennium Development Goals (MDGs).8 The adoption of the MDGs by donors and many developing country governments has been one of the most important external drivers of a move towards a greater focus on the outcome of years of development aid. Analysing outcome improvements in relation to aid spending (per programme, per sector or per country), led to the realisation that improving public service infrastructure alone is not enough - the quality of public services delivered by frontline service providers holds many countries back from achieving their development goals (Travis et al 2004).
Within the health sector alone, the drive to improve health statistics and achieve the health-focused MDGs has had positive as well as negative consequences for public health facilities in developing countries. MDG goals three, four and five, are commonly known as the ‘health MDGs’, focussed on a reduction of child mortality, on reducing maternal mortality, and on combatting HIV/AIDS, malaria and other diseases. These three goals have ensured that governments and donors have channelled significantly more resources and manpower than previously to these specific health problems, in an attempt to meet the 2015 target deadline (UN 2011). The focus on tackling MDG-related health issues was revealed by Dieleman et al (2016) who calculated development assistance for health (DAH) spending between 1990 and 2015:
Linear regression identifies three distinct periods of growth in DAH. Between 2000 and 2009, MDG-related DAH increased by $290·4 million (95% uncertainty interval [UI] 174·3 million to 406·5 million) per year. These increases were significantly greater than were increases in non-MDG DAH during the same period (p=0·009), and
8 The Millennium Development Goals were replaced by a new set of development targets called the Sustainable Development Goals in September 2015. It is too early to tell whether these goals will have a similar impact. 52
were also significantly greater than increases in the previous period (p<0·0001). Between 2000 and 2009, growth in DAH was highest for HIV/AIDS, malaria, and tuberculosis. Since 2010, DAH for maternal health and newborn and child health has continued to climb, although DAH for HIV/AIDS and most other health focus areas has remained flat or decreased. (Dieleman et al 2016)
One downside of the health MDGs’ successes is that, by and large, these health achievements are attributable to so-called ‘vertical programmes’, which are often implemented as interventions targeting only one particular issue or disease. So-called vertical health interventions are often implemented with little coordination with the existing public health system, and no intent to improve it. Bhutta et al note: “Coverage of interventions delivered directly in the community on scheduled occasions was higher than for interventions relying on functional health systems” (2010, p. 2032).
The widespread use of vertical programmes can undermine weak health structures in developing countries by the recruitment of the best public sector staff to ‘vertical projects’, causing wage expectations to increase and creating temporary parallel systems for vaccinations, anti-retroviral drugs distribution, etc. While health indicators have improved, and lives have been saved, these interventions have brought few sustainable improvements to developing country health services (Crisp and Chen 2014,
Vujicic et al 2012, Waage et al 2010). An assessment of sector-targeted donor spending concluded “significant expansion in the quantity of services being delivered, but there has been far more limited progress in improving the quality of those services and the equity with which they are delivered” (Williamson and Dom 2010, p. 2).
Nevertheless, health gains in developing countries have been significant. In 1990, 12.7 million children under five died annually; in 2015 this number was reduced to almost 6 million. Liu et al justly describe progress in child survival worldwide as “one of the greatest success stories of international development, with child deaths being reduced 53 by half in the past two decades since the MDG baseline” (2015, p. 435). The 2015 UN
Millennium Development Report noted: “Though sub-Saharan Africa has the world’s highest child mortality rate, the absolute decline in child mortality has been the largest over the past two decades. The under-five mortality rate has fallen from 179 deaths per1,000 live births in 1990 to 86 in 2015. Yet the region still faces an urgent need to accelerate progress” (2015, p 33). Sierra Leone did not meet any of its MDG health targets, a 2014 report with the latest statistics available to date, shows that by the end of 2015 the country’s under five mortality rate was 182 death per 1000 live births – the
MDG target was 86 – and its maternal mortality rate remains stubbornly high at 1100 deaths per 100,000 live births – almost double its 2015 MDG target of 580 (WHO
2014b).
Despite the MDGs’ accomplishment in focusing attention, efforts and funds to improve health indicators in Africa, few have had long lasting positive impact on the health systems. Recent studies continue to document the unchanged working conditions for health care staff: staff shortages remain acute; pay and morale remain low; and health care staff are not engaged in policy debates that could improve their conditions (Manongi et al 2006, Manzi et al 2012, Serneels and Lievens 2008b). This foreshadows the need for social accountability interventions in this sector for the foreseeable future.
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2.5 Conclusion
Chapter two has provided an overview of the literature that is relevant for the undertaking of this research project. An analysis of the social accountability literature, the literature on corruption and on human resources for health has highlighted the fact that there are four recurrent themes that appear to contribute to successful social accountability interventions. These four themes are: the redressing of information imbalances, citizen participation, power and political awareness and staff motivation.
As I highlighted at the start of chapter two, there are no established analytical frameworks for social accountability, and I will therefore use these four recurring themes to guide my empirical analysis of the social accountability interventions.
All social accountability interventions contain elements that aim to redress the existing information imbalance. Citizens often lack knowledge about what services they are entitled to. In addition, they are unaware of the basic standards of service their local clinic or school (or other street level public service point) should provide. Citizens are often unable to compare the service they receive to either the minimum standard or to the service neighbouring facilities provide. Providing comparative service level data can be a catalyst to collective action.
Section 2.2 of this chapter, highlighted the fact that citizen participation is key to social accountability. People’s sense of citizenship has a substantial impact on the level to which individuals are willing and able to engage in ‘citizen actions’ such as social accountability interventions. Several texts were highlighted which provided evidence that causality runs both ways: engagement in citizen action can lead to a significant improvement of a person’s sense of ‘being an active citizen’, while communities where
55 a sense of citizenship already exists are often more willing and able to participate in accountability interventions. Social accountability interventions that aim to improve basic public services cannot be implemented without some level of engagement of individuals who can be considered the ‘service users’.
The social accountability and the corruption literature stressed that an awareness of power dynamics and the political drivers that influence the provision of basic services are of utmost importance for the design and implementation of social accountability interventions. The logic is simple: many services are not provided to the best possible standard because individuals or groups may benefit from a diversion of goods or time spent at work. No intervention can change the status quo without having a clear insight as to how service improvements would affect such arrangements. Finding the right incentives to encourage people to improve service provision is often the key to a successful intervention.
Finally, the human resources for health literature highlights the importance of staff motivation in relation to the provision of the best possible healthcare. It shows that there is a correlation between the monitoring of health service (as part of a social accountability intervention, for example) and the motivation of healthcare providers.
Too much intrusive monitoring can undermine motivation, whereas monitoring that provides positive feedback may well have a motivating effect. Moreover, when a motivational element is introduced in a work place, it is important that the sustainability of the motivational trigger is considered; e.g. salary top-ups are only viable motivators if they can be sustained.
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In the next chapter on methodology, the four key themes highlighted in this chapter will be used to construct an analytical framework that can be used to assess the suitability of the methodologies reviewed during the empirical research for this study.
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Chapter 3 - Methodology
3.1 Introduction
This chapter will outline the methodological considerations for this study. In particular it will provide the rationale for choosing the methodologies that were selected in order to answer the research questions:
(i) Why and when do social accountability interventions aimed at improving public service delivery, succeed or fail?
(ii) What effects do social accountability interventions have on frontline staff in healthcare facilities?
(iii) How can social accountability methodology be improved?
To describe the research process this chapter firstly presents an analytical framework to examine social accountability interventions using the four key themes outlined in the last chapter. It then details the research design, including the rationale for selecting
Sierra Leone as a study site and reasons for choosing the individual case studies. It furthermore goes on to describe the data collection process before finally addressing the issue of data analysis.
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3.2 The analytical framework for social accountability interventions
This research set out to compare four accountability interventions, based on their methodological differences, in order to analyse which components of social accountability methods contributed to its success or failure. The methodological differences were compared to the extent to which each of the projects had achieved its stated objective (which, in all four cases, was ‘improving primary health service delivery through the promotion of greater accountability’), while other influencing factors were also taken into account.
The literature on social accountability provides few examples of rigorous comparisons between accountability methodologies. Even those texts that do analyse a range of interventions, often map the interventions by outcomes rather than inputs, or methodological distinction. Finding useful methodological commonalities within the social accountability literature therefore involves assessing individual articles, grey literature and comparative analyses case by case. Studies present different contexts and different foci, which makes it difficult to distil any common variable that is the cause of success. Chapter two demonstrated that the review of the existing social accountability literature points to other literatures such as corruption literature and sector specific literature (human resources for health, in the case of this research) that need to be taken into account in order to gain a thorough understanding of which key components a social accountability intervention need to incorporate in order to have a good chance of succeeding.
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In constructing an analytical framework appropriate for the study of social accountability methodologies, four key areas emerged from the literature as the key components on which accountability interventions should be assessed:
1. Redressing information imbalances 2. Citizen participation 3. Power and political awareness 4. Sustainable staff motivation
During the empirical research, these four elements provided the pillars of the analytical framework deployed in this study. The framework will be used to compare each method in order to elucidate clues as to why the interventions varied strongly in their outcomes.
3.2.1 Operationalising the four key themes of the analytical framework
The analytical framework guides the empirical research into social accountability interventions in Sierra Leone. The four key themes will be operationalised in the following section.
3.2.2 Redressing information imbalances
Ample studies on corruption in the health sector (Lewis 2006, Savedoff 2011, Vian
2007) demonstrate that in a healthcare setting, an information imbalance always exists.
These imbalances are caused in part by the health workers superior technical knowledge, and the fact that few governments can sustain information campaigns that ensure that patients are at all times aware of their rights, entitlements and existing
61 health service standards. Especially in low-resource settings, funding the dissemination of such information is often a low priority compared to the funding of actual healthcare delivery (Loewenson 2000, Vian 2008). Studies that have examined the problem of low quality healthcare provision found that it is often these information imbalances that can be exploited by healthcare providers in order to mask their absenteeism, lack of effort or malfeasance (Bjorkman, de Walque and Svensson 2014, Leonard 2005).
In a bid to improve accountable behaviour in the health sector, information is key.
Information is an important component in social accountability methodology and can be a powerful tool in the hands of citizens (Bjorkman, de Walque and Svensson 2014,
Brinkerhoff and Azfar 2006, Joshi 2010b, Lieberman et al 2012). Brinkerhoff et al hold that ‘access to information’ is a vital part of being empowered: “[…] definitions of empowerment have expanded to include: having access to information and resources, having a range of choices beyond yes or no, exercise of “voice” and “exit,” feeling an individual or group sense of efficacy, and mobilizing like-minded others for common goals” (2012, p. 5). However, the literature on access to information reveals that while an information component is crucial to successful social accountability interventions, having an information component as part of such an interventions is by no means a guarantee that the intervention will be successful (Fox 2007, Joshi 2010b).
The main roles that information can play in social accountability interventions are twofold: first of all, the provision of details about entitlements and service standards
(staffing levels, opening hours, other obligations a facility should adhere to) aims at reducing information imbalances between service users and service providers.
Eliminating service users’ lack of knowledge about standards and entitlements can empower them, making it less likely that service users are too intimidated to speak out.
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Secondly, the provision of information on how the services received by the intervention’s target group, compared to those received by neighbouring communities, should also act as a catalyst that can drive citizens to take action, participate in the social accountability intervention or overcome collective action problems and act on governance issues, on the basis of playing on citizens’ sense of unfairness: “if they can have services to a high standard, so should we”.
To assess the ‘redressing information imbalances’ component of social accountability methodologies, practical details will be examined. It is important to evaluate to what extent the project was designed to address the existing informational imbalance. This can be assessed by reading the programme documents and examining the situation analysis that preceded the project design. Subsequently, the extent to which the intervention responded to the existing informational imbalance can be evaluated. All information provided will also be assessed in terms of its relevance to the project and its relevance to people’s lives: in other words, does the information provide the type of detail that service users can understand, relate to and act upon? Finally, the information provided will be judged on its format, accessibility and its completeness, in other words, did the information provide people with an understanding of the issues, and can illiterate people understand it too, or did it raise further questions or cause confusion?
If the latter was the case, was this because the messages were not delivered in a coherent way that enabled people to grasp the full details, or were other issues to blame?
While most information in social accountability interventions is directed at citizens, interventions can at times also contain information that is directed specifically at service providers. This information will also be assessed in terms of relevance,
63 accessibility and on its impact in relation to the project’s objectives. The overarching question here will be: how much did the information component contribute to the overall impact of the intervention? In sum, the following indicators are used to assess the redressing information imbalances component:
Nature of the information gathered and provided (entitlements, service provision standards, etc.)
Relevance of information gathered and provided (easy to understand, does knowing this matter to people)
Target of information provision (service users or service providers)
Impact of information provision (catalyst, equalising power relations)
3.2.3 Citizen participation
Social accountability interventions are based on the participation of citizens. In a successful social accountability intervention, the citizens are encouraged to apply the right level of social and peer pressure (McGee and Gaventa 2010, p. 5) which can lead to more accountable behaviour on the part of local service providers.
Achieving equitable community participation, however, is a challenge. This was discussed in chapter two: while many interventions start out with the intention of ensuring that all sections of a community are represented fairly, in practice, it is difficult to make sure that such goodwill does not get hijacked and fall victim to elite capture. The need to achieve quick results can lead to the hasty establishment of working relationships with those who present themselves as spokespersons for a community, who are often vocal and literate individuals who do not always fully represent the views of people from marginalised groups or genders, those of minority ethnicities, or certain age-groups (Cooke and Kothari 2001, Cleaver 1999, McGee and 64
Koesschel 2013). In most cases, interventions have limited time and budgets to ensure good citizen participation and as a way of ensuring some representation of a cross section of people within a community, representatives of different citizen groups are required to take part. For example, a group of community representatives can be invited to take part in a citizen-service provider dialogue, with the stipulation that there should be a gender balance and that the group should include people of several different age ranges, or represent certain minorities, people with disabilities, etc.
In Sierra Leone citizen engagement structures within the health sector exist throughout the country. Many of these were initially established when health facilities were renovated or rebuilt after the war. In 2012 the Sierra Leonean NGO Health for All
Coalition was tasked with setting up Facility Management Committees (FMCs) throughout the country. For some of the interventions studied, these existing FMCs were the first entry point within a community, and sometimes the FMCs became the key focal point of the intervention. In other interventions FMCs were not engaged at all.
Assessing whether social accountability interventions are successful in achieving broad based citizen participation and if it thereby manages to empower those who are involved in the intervention will require both an examination of the initial proposal of each project and its implementation. Strategies which are incorporated to realise inclusive citizen participation are not always successful; only empirical data collection can confirm whether such strategies led to actual broad-based participation at grassroots level.
Based on these observations, the following indicators were selected:
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Whether or not broad based participation was an element of the initial project design
If the intended participation was achieved (fully or partially)
The impact, if any, of the citizen participation component
3.2.4 Power and political awareness
“The power relations that underlie poverty and exclusion can make or break development programmes, if not understood and addressed at all stages of design and implementation” (Pettit and Acosta 2014). The third criterion for the empirical research of social accountability interventions is the level of awareness of power and politics which is embedded in the methodology of each intervention. This will be assessed in the broadest sense, taking into account whether the interventions’ theories of change contain (in theory and/or in practice), an awareness of, and an inbuilt response to the greater power and political implications of the project - at local and at national level.
It is critically important that the issue of power is understood and imbedded in the design of a social accountability intervention. Much of the unaccountable behaviour that health workers engage in is often tolerated or endured because of the position of power that healthcare professionals occupy. In remote rural communities there is only one situation that is worse than having to cope with a corrupt health worker and that is having no health worker at all (KI94)9. This basic fact allows many health service
9 This reference is from a primary source, all codes can be found in Appendix B, where details such as names (unless anonymised), dates and locations of all interviews and focus group discussions can be found. 66 providers to exploit their position, knowing that the communities that use the clinic would be reluctant to report misbehaviour.
The health worker-community relationship is not the only power relationship that exists within a community, there are many more relationships that each carries its own weight and needs to be considered carefully. The literature on health and accountability mechanisms suggests that recruiting and working with local health committees bring their own challenges: as much as they can be a positive force, there have also been cases in which village health committees were found to collude with healthcare staff, and cases where they used their influence to procure superior treatment for those who paid them (McPake 1999). Ironically, it seems likely that the
Sierra Leone government’s drive to reduce home births has driven traditional birth attendants towards health facilities, where they are dependent on the health worker in charge to arrange a way to compensate the traditional birth attendant for her assistance
(Health Poverty Action 2012). This seems to have further strengthened the hand of the health worker. However, many traditional birth attendants are also known to occupy powerful positions in Sierra Leone’s many initiation structures (so called ‘secret societies’), which greatly influences the power and status of certain women in rural communities (Fanthorpe 2007).
In addition to community-based power dynamics, social accountability interventions in the health sector in Sierra Leone should also take account of established oversight mechanisms. The District Health Management Team (DHMT) is part of the District
Health Authorities and their members have been delegated by the Ministry of Health and Sanitation to carry out regular supportive supervision visits to all clinics. Despite the fact that there are few known cases where health workers were reprimanded for
67 inappropriate behaviour (KI94), the District Health Authorities do have considerable power over the health workers in their district. The potential to leverage the community-based monitoring of health workers by engaging health authority staff should therefore not be overlooked. At district level, there are other stakeholders, such as the District Council, made up of elected representatives (councillors) who are responsible for external oversight regarding the provision of public services. Linkages to both of these groups could provide vital ‘feedback loops’ (information on accountability problems that allows them to intervene), and should be a component of all good accountability interventions (see, for example Tembo 2013, p. 66).
In addition to power imbalances, there are also political implications with regards to implementing accountability interventions in the health sector. The failure of accountability affecting the Free Healthcare Initiative is politically sensitive: The programme is often referred to as ‘the President’s Free Healthcare’10 and advocacy surrounding accountability in the health sector does not come without political considerations. This was a sensitive topic, and several key informants hinted at the fact that being too vocal about the problems related to the free healthcare were generally considered as ‘siding with the opposition’. Such accusations can be dangerous for individuals, but they do not always have negative consequences: being a vocal citizens rights’ advocate has landed several activists a career within the ruling or the opposition party in the past (Fanthorpe and Maconachie 2010, p. 265). In Sierra Leone it seems more likely that vocal government critics are silences by getting ‘bought off’, as it is called, with a job or a lucrative contract, than in any other way.
10 Although the initiative is almost exclusively funded by donors - which is a different political issue. 68
Measuring power and political awareness was not easy. The simplest solution was to screen if implementing NGO staff had knowledge of certain basic power and political awareness facts; i.e. did they understand how a ‘lack of accountability’ manifests itself in the health facilities where the interventions were implemented? Staff who were involved in social accountability interventions were also asked about how they dealt with issues of power during dialogue sessions between service users and health workers.11 Programmes were assessed in relation to the strategic connections each intervention facilitated with other power holders such as the district health authorities and district council staff, and how these relationships were used as leverage.
The indicators therefore consider if there was evidence of:
Awareness of common accountability deficits among NGO staff, and how they affected health service users
Strategies to address power imbalances at community level
District-level linkages that were used as leverage to address accountability failures
3.2.5 Sustainable staff motivation
While social accountability methodology would be expected to focus on the ‘social’ as much as on the ‘accountability’, there are few, if any, texts that explore the ‘social pressure’ aspect of the methodology in great detail. Many critics of social accountability would argue that citizen-led or public initiatives involve ‘soft’ peer or reputational pressure and therefore rarely involve ‘strong enforceability’ (McGee and
Gaventa 2011, p. 11). The potential of social and reputational pressure is often
11 Especially how they handled potential power differences in the way the community and the health workers evaluated the health services provided, which were discussed during community monitoring and quality circle dialogues. 69 underestimated, as is the motivational power of a good relationship between the citizen and the service-providers, or the incentive to improve working practices when there is a prize to be won for best performing service provider or most improved institution.
Staff motivation can greatly influence the behaviour of public service staff, contributing to how accountable, or not, staff act at work. Surprisingly, the motivating or de-motivating effect of social accountability interventions on the personnel subjected to the intervention is routinely ignored. The intrinsic motivation of healthcare staff is a precious commodity, not to be undermined in the process of attempting to improve accountability.
The interventions will be evaluated on the efforts to include healthcare staff during the design and implementation of the programme, and inbuilt motivational components will be evaluated on their suitability and evident success. Implementing NGO staff will also be asked about their awareness of staff motivation and their approaches to motivation during the implementation of the projects.
The indicators for staff motivation are as follows:
Presence of / approaches to motivational elements within intervention Levels of awareness of the role of staff motivation with regards to staff behaviour In interventions with an award: was the award suitable regarding intrinsic motivation? In interventions with an award: did it offer an incentive to improve behaviour?
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3.2.6 The intersection between the various analytical framework components
The four framework components discussed above are general themes that are examined in isolation for the sake of this research. This should not be done without acknowledging that a great deal of interplay or interaction occurs between the components. Redressing the information imbalance is all about trying to redress the balance of power – and while one doesn’t always lead to the other, these connections between the two components will be explored in the analysis chapter 9. Information and power are not the only two components that share commonalities; power and lack thereof is also an element at play when participation is examined. Who participates and who does not, is often related to the relative power of an individual or a group and the estimated gains that are expected from participation. Finally, information and staff motivation are also connected, often in a positive way. The greater transparency in staff arrangements such as salary scales, career progressions, job descriptions and the availability of bonuses, the greater the likelihood of staff motivation.
All of these intersections will be explored in the case study chapters’ analyses sections and at the final analysis in chapter 9.
3.3 The research design
3.3.1 Adopting a case study approach
For the empirical research on which this thesis is based, I elected to compile four ethnographic case studies, on each of which contextual information is given on a common set of characteristics. Each of the four cases represented one of the social 71 accountability interventions I focused on. These are subsequently examined in detail, using a common analytical framework in order to make the analysis of a broader application and use than a single-case-bound analysis would.
According to Yin (2003, p. 13) a case study is “an empirical enquiry that investigates a contemporary phenomenon within its real-life context, especially when the boundaries between the phenomenon and context are not clear.” Gerring’s definition is as follows:
[…] I propose to define the case study as an intensive study of a single unit for the purpose of understanding a larger class of (similar) units. A unit connotes a spatially bounded phenomenon-e.g., a nation-state, revolution, political party, election, or person-observed at a single point in time or over some delimited period of time.
(Gerring 2004, p. 342)
By using four ethnographic case studies, the empirical research presents an opportunity to intensely scrutinise what occurred at each of the site of each of the four social accountability interventions, and how it related to these programmes. Each of the case studies was compiled using a broad range of interviews and focus group discussions which, combined with extended periods of time spent in the research location, allowed me to develop a deep understanding of the lived realities and the context in which each of the interventions took place. After the field research phase was completed, the knowledge derived from each of the four cases was examined using the analytical framework introduced earlier in this chapter, to test if there were common themes among the four cases.
In using the research methods described above, I acknowledge that the research design creates some tensions by using, on the one hand, a structured comparison (by applying the same analytical framework to all four cases), and on the other, a post-positivist,
72 anti-foundationalist epistemological stance by using an ethnographic approach in data gathering.
There are good reasons for doing so; scholarship on the subject matter, social accountability methodology, has shown ever greater emphasis on the each intervention’s need to be aware of contextual dynamics, or that “context matters”
(Cornwall et al 2011, Joshi 2013, Joshi 2014, Tembo 2012). This study aims to learn from and respond to these studies by delving deep into the context of the four interventions under study to find out in what way context matters and how each of the intervention had (or had not) responded to contextual challenges. At the same time, this study endeavoured to produce, in greater detail, insights into why social accountability interventions succeed or fail. The latter demanded some level of comparison and cross case learning so as to be able to discover and examine commonalities.
3.3.2 Ontological and epistemological stance
My proposition to subject a series of ethnographic case studies to a certain level of comparative analysis, pointed me in the direction of an ontology and epistemology that best accommodates this slightly contradictory stance. This led to a decision to adopt a critical realist perspective. Roy Bhaskar’s critical realist philosophy has been interpreted by many of his adherent in a variety of ways. Easton (2010) primarily draws on the interpretations of Sawyer (1992, 2000). According to Easton:
Critical realists propose an ontology that assumes that there exists a reality “out there” independent of observers. A naïve realist epistemology would assume that this reality can be readily accessed. This is a view often espoused by researchers in the natural sciences because of their ability to measure accurately and their access to controllable
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and / or closed systems. However these conditions rarely occur in social systems. As a result critical realists accept that reality is socially constructed […] thus creating a tension between these apparently contradictory views. However critical realists resolve the tension by arguing that the world is socially constructed but not entirely so. The “real” world breaks through and sometime destroys the complex stories that we create in order to understand and explain the situations we research.
(Easton 2010, p. 120)
After studying several interpretations of Bhaskar’s work and propositions of how his philosophy can be interpreted for the use of social science research (Danermark et al
2002, Easton 2010, Grix 2004, Houston 2001, Lewis 2002) I felt confident that by adopting a critical realist approach it was possible to conduct a somewhat loosely structured comparison between the four cases, examining causal linkages between the social accountability interventions and the outcomes, in the way a positivist might do
(Grix 2004, pp. 79-82), while at the same time using in-depth case study detail in an more interpretivist way (Grix 2004, pp. 82-84), taking into account the fact that the interventions’ beneficiaries, as actors, respond to the different social accountability programmes in ways that are mediated by the social structure in which they find themselves. Easton suggests that “Critical realism is particularly well suited as a companion to case research. It justifies the study of any situation, regardless of the numbers of research units involved, but only if the process involves thoughtful in depth research with the objective of understanding why things are as they are” (2010, p. 119).
3.3.3 Case selection
At the research design stage, Swanborn’s advice was followed: “In selecting more than one case, the usual procedure is to design a tentative model based on the results of the
74 first studied case, and to adjust the resulting model when and where necessary while studying the other cases, until the designed model fits all cases” (2010, p. 3).
As the starting point for the research design, the most common social accountability methodology, ‘community monitoring with score cards’ was taken as the first case, and the starting point for the research design.12 This intervention has been widely used in the health and education sectors in numerous developing countries. The assumptions of what the impact of such an intervention might be in Sierra Leone were therefore not only based on the ‘theory of change’ described in the implementing agency’s documentation, but also on texts that have described similar interventions in other countries (Arroyo and Sirker 2005, Barr et al 2012, Björkman and Svensson 2007,
McNeil and Mumvuma 2006, Ringold et al 2012, Thindwa et al 2005). I decided on the final case selection after my scoping visit to Sierra Leone in 2012. The following research design was constructed, taking into account the interventions that were to be studied, and the analytical framework that had been designed prior to the empirical study:
Case A examines the implementation of the Community Monitoring with Score Cards
(CM) methodology, which, according to research evidence, is expected to lead to enhanced accountability and improved service delivery outcomes. I compare this case to three other cases, which all have the same objective: increased accountability and improved health service delivery. The methods used in cases B, C and D all vary, and the variations in their methods should allow for inferences to be drawn about the
12 In advance of the initial scoping visit to Sierra Leone, I had received programme documents that indicated that one of the Christian Aid partner agencies, NMJD, was planning to implement a Community Monitoring intervention. During the scoping visit it became clear that the agency did not have the know-how nor the budget to do so, and a simplified intervention was chosen instead – additional components were later added, which led to my decision to call their intervention ‘Mixed Methods including Quality Circle’. At the time the study was broadened to four interventions, a Community Monitoring intervention was searched for (and selected), though this was not the deciding factor to include the two Tonkolili-based interventions. 75 effectiveness of certain key components of social accountability within the Sierra
Leone context.
The idea of studying several interventions with similar but subtly different methodologies was inspired by the Björkman and Svensson’s follow-on study in
Uganda (2011), in which a community-driven development method was examined, which was modified to be largely identical in implementation to their successful community monitoring trial (2007) but without the information component. Being aware of the fact that a multitude of ‘accountability interventions’ were being implemented in Sierra Leone as a response to the pervasive corruption and mismanagement of the Free Healthcare programme, my research design, in advance of the 2012 scoping visit to Sierra Leone, was based around the idea that it should be possible to find four accountability interventions that were similar but subtly different - different enough to design this study around.
The case selection was based on a series of considerations, both theoretical and practical. During the initial literature review it became clear that the implementation of social accountability interventions in fragile states had received much less attention than similar programmes operated in developing countries where post-war state legitimacy problems are no longer an issue. In order to fill this identified knowledge gap, the fragile state environment in which social accountability methodologies were being implemented, became one of the determinants of the case selection, so while the selection of cases was primarily focused on social accountability mechanisms, the fragile state implementation context was the second criteria used to determine the selected cases.
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The case selection started with practical considerations. Having collaborated with the
Irish NGO Concern during previous academic research (for an MPhil in Peace
Studies), I felt a strong personal preference to work in partnership with an NGO that uses social accountability interventions and was open to increase its learning about the methodology. The opportunity arose to work with Christian Aid Ireland (CAI) and this led to a successful research collaboration. The research partnership provided the opportunity to conduct a study into the methodological differences of two accountability interventions in the health sector in Sierra Leone supported by CAI.
The interventions were a Participatory Monitoring and Evaluation (PM&E) programme implemented by CAI’s partner organisations SEND Foundation in
Kailahun District, and a Mixed Methods intervention which included a Quality Service
Circle element (MM/QSC) implemented by NMJD in Kono District.
Having committed to focusing on these two social accountability interventions, it soon became obvious that while the interventions shared the same objectives, but were methodologically too distinct to allow for a reasonable comparison. In order to balance out these differences, it made sense to select two further cases, which would provide a better opportunity to single out individual methodological traits that set each intervention apart. The selection of the additional two cases was based on two criteria; firstly, they needed to be methodologically similar enough (but not the same) as the two interventions already selected and secondly, they needed to be implemented in locations that were comparable enough to the two Christian Aid projects (which were located in Kono and Kailahun, see map, below).
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Figure 3: Map of Sierra Leone with district boundaries
Kono and Kailahun were sufficiently similar with regards to key structural features: both are rural areas, remote, bordering Liberia and/or Guinea - badly affected by the civil war, and remain among the poorest in the country13 (Himelein 2013). A poverty map of Sierra Leone shows that in 2011, 61.3% of the inhabitants in Kono and 60.9% of the people in Kailahun lived below the poverty line, which was defined as
“individuals living in households with per adult equivalent consumption below
1,625,568 Leones per year”14 (Himelein 2013, p. 9).
13 © Ministry of Local Government and Rural Development, Government of Sierra Leone. Please note that the capital Freetown is located in “Western Area Urban”. 14 Which was 375 US$ per year using the 2011 exchange rate. 78
During my exploratory field visit to Sierra Leone in September 2012, I was able to gather information about the activities of several NGOs which also implemented social accountability interventions in the health sector. There was a significant number to choose from, which made it possible to select two additional social accountability interventions.
The two additional interventions that I selected to study were a Community
Monitoring with Scorecards project and a Non-Financial Awards programme, both implemented by the Irish NGO Concern. The methodological match was ideal, by selecting a Community Monitoring intervention, I had an ‘anchor’ method about which a lot of literature already existed. This method became my starting point. The Non-
Financial Awards programme was a good fit for the Participatory Monitoring and
Evaluation intervention, considering both featured a competition for health workers as a way of incentivising improved working practices. Because both programmes were implemented by the same international NGO, it conveniently limited the number of organisations involved from which I needed to obtain permission to conduct research at the clinics where these two interventions had taken place. Both interventions were implemented in Tonkolili District, which matched the remote, rural and poor environments of Kono and Kailahun Districts. The following section will provide greater details about the compatibility of the three districts.
3.3.4 All things being equal
The four cases that I selected for this research project were located in three different districts:
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Community Monitoring with Scorecards in Tonkolili District Non-Financial Awards in Tonkolili District Participatory Monitoring and Evaluation in Kailahun District Mixed Methods with Quality Service Circle in Kono District
This section presents the rationale behind the selection of the three locations. It acknowledges that social research in the real world will never be able to present the researcher with clean cut examples in which variables can be compared while everything else is equal. However, I agree with Collier and Mahon, who used examples in which academics compared ‘communist regimes’ or ‘political participation in the United States and four other countries’ to show that real life comparison is extremely important in social science, and therefore developed a way of analysing a range of variables in order to be able to prove that, taken as a whole, they can be considered exogenous (Collier and Mahon 1993).
Based on Collier and Mahon’s work on “conceptual traveling (the application of concepts to new cases) and conceptual stretching (the distortion that occurs when a concept does not fit the new cases)” (1993, p. 845), the table below shows that when a number of ‘external environments variables’ which influence the marginality of each district are jointly taken into account, the districts of Kono, Kailahun and Tonkolili are arguably similar enough to allow these variables to be considered exogenous, and the differences in the methods of social accountability interventions can be considered as the independent variables. This is based on Ludwig Wittgenstein's idea of family resemblance, as cited in Collier and Mahon, who explain that the family resemblance concept:
[…] entails a principle of category membership different from that of classical categories, in that there may be no single attribute that category members all share. The label for this type of category derives from the fact that we can recognize the members of a human genetic family by observing attributes that they share to varying degrees, as contrasted to nonfamily members who may share few of them. 80
(Collier and Mahon 1993, p. 847).
The approximate comparability of the external environments of Kailahun, Kono and
Tonkolili, based on the ‘family resemblance’ theory, is mapped out in table 1, below. It is based on the following facts: All three districts were among the six most damaged areas during Sierra Leone’s civil war: Wang’s report on education facilities, based on a
2004 research report, shows that the large majority (between 70-85%) of school facilities in those six districts were completely destroyed or in need of major repair or restauration (2007, p. 69).
Table 1: A mapping of variables based on factors that indicate or contribute to the marginalisation of three districts: Tonkolili, Kono and Kailahun.
Variables: Case 1+2 Tonkolili Case 3-Kono Case 4-Kailahun
War damage End of war-location Early on, due to Early on, due to of key RUF bases border location and border w Liberia + rebel’s efforts to Guinea control diamond mines Post-war poverty- 2nd poorest 11th poorest (out of 3rd poorest urban (Wang, 2007, 12 districts) based p 21) on diamond revenue Post-war poverty- 5th poorest 7th poorest 2nd poorest rural (Wang, 2007, p 21) Recent poverty Poorest overall- Poverty headcount Poverty headcount levels (Himelein, poverty headcount 61.3 60.9 2013, p. 9) 76.4% Remoteness Less remote, central Also very remote, Most remote (no SL location, but few bordering Guinea tarmac road from tarmac roads Freetown-district throughout district capital) Mining Yes Yes None Mining-related Yes Yes None corruption Ethnically mixed No Yes No Support ruling party Yes (but no Swing state, but No in recent years influential cities to voted SLPP in last (APC) benefit-lost out election against Makeni)
Key: the red, amber and green colours meaning (respectively) that the district is severely, moderately or not affected by each of the factor
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In the same report, a poverty index for 2002/3 ranks Tonkolili and Kailahun among the five poorest districts when it comes to urban or rural poverty (2007, p. 21). Tonkolili and Kono are both considered wealthy in terms of extractives (diamonds in Kono make it the richest district on paper), but this wealth is offset by the corruption that the industry brings and the local and national governments’ tendency to pander to the mining companies rather than the population (Curtis 2014).
Kono is also one of the most ethnically mixed districts, which can undermine social coherence (Pellegrini and Gerlagh 2007). Kailahun, on the other hand, is largely populated by people from the Mende tribe. There is greater social cohesion and as an agrarian district, it is less influenced by the diamond politics of Kono. Tonkolili is also ethnically homogenous, predominantly Temne, and is considered a northern district, despite being located in the centre of the country. The district’s voting patterns
(Casey 2013, Kandeh 2008) are staunchly APC, as the predominance of Temnes would suggest, which makes Tonkolili a government supporting district. Kailahun is a well- known SLPP (i.e. opposition) supporting district and Kono a swing state. All three districts are still among the poorest districts in Sierra Leone: a 2013 World Bank report lists the percentages of the population living below the poverty line as 76.4 in
Tonkolili, 61.3 in Kono and 60.9 for Kailahun (Himelein 2013, p. 9).
3.3.5 Scoping visit
In September 2012, an opportunity arose to conduct a ‘scoping’ visit to Sierra Leone facilitated by Christian Aid Ireland. This allowed me to meet with staff from Christian
Aid’s two local partner organisations, SEND and NMJD, and to visit Kono and
Kailahun, where their accountability interventions were being implemented. It also 82 meant that the two partner agencies and Christian Aid Sierra Leone could get a better understanding of what benefits the research would bring them. At the same time, it allowed me to get a sense of what their projects looked like, to try out interview and focus group discussion guidelines, and obtain a brief glimpse of the operating environment. At that time SEND’s Participatory Monitoring & Evaluation project in
Kailahun had already been implemented for almost a year. The visit to two health centres in Kailahun gave a good indication of the type of interviews and focus group discussions that could be conducted. It allowed me to gauge people’s responsiveness and the time it took to go through the pilot questionnaires. The majority of the interview guideline adjustments were based on the interviews and focus group discussions that were conducted in Kailahun (which included key informant interviews as well as health centre-based discussions).
In Kono, it was clear that the agency NMJD had not yet started the implementation of their intervention. In preparation for the visit, Christian Aid had made it clear to me that NMJD had been requested by CAI head office, as part of donor (Irish Aid) funding requirements, to identify a series of baseline indicators for their forthcoming intervention. It was suggested that I could assist NMJD with their brainstorming on the issue, and it was clear that NMJD was open to receiving some form of guidance during the scoping visit.
During the visit, problems regarding NMJD’s implementation plans, which turned out to be much broader than just baseline study issues, brought about several dilemmas about my identity and positionality as ‘the researcher’. By specifically choosing to collaborate with an international NGO, I had committed myself to being ‘of use’ to the agency and its local partner organisations. The key reason for choosing to collaborate
83 with an NGO was because such collaborations often increase the research’s impact. It is usually more likely that a collaborating NGO will take note of study findings if they have been developed by their own staff in conjunction with a researcher, or if the NGO has identified a particular issue that it wants the researcher to give for ‘free’ advice on during the course of the research collaboration.
In this particular case, I was called on to support NMJD, one of the implementing agencies, with a significant reorientation of their project proposal. It was overambitious, but also, as it turned out, it would be duplicating the efforts of a nationwide health monitoring campaign which had just started. Helping NMJD with the redrafting of their proposal (which included a revision of their methodology), meant that I influenced (to some extent) one of the subjects of my research. I chose to depart from my role as an independent, observing researcher and instead I decided to share my knowledge of social accountability interventions and of NMJD’s previous programme evaluations15, as this seemed the most ethical thing to do. Further details of the re-writing of NMJD’s project proposal are included in chapter eight. The re-written programme proposal was subsequently adopted by NMJD and by Christian Aid and became the blue print of the intervention that was examined for this research in May
2014.
15 Christian Aid had provided me with several recent programme evaluation documents produced by NMJD, which I had studied carefully in advance of visiting Sierra Leone. 84
3.4 Data collection overview
The following section describes which research methods were chosen to conduct the field research for this study and it provides an insight into several challenges encountered in the process of gathering data.
3.4.1 Sampling
In this study, a total of 31 health workers16 and 35 groups of clinic users were targeted for interviews and focus group discussions. They were selected using purposive sampling, which means that they were “selected according to predetermined criteria relevant to a particular research objective” (Guest et al 2006, p. 61). The health workers17 were selected because they had been involved in one of the four social accountability interventions, and the focus group discussants were selected because they were users of the clinics involved in the study.
The selection of the clinics that were targeted for this study was guided by a number of considerations. Time (my own and of the NGO staff I visited) and budget were limiting factors. It was important to visit a similar number of clinics in each of the programme areas. NMJD’s intervention targeted only ten clinics for its Mixed
Methods with Quality Service Circle (MM/QSC) approach; I visited nine of them (i.e.
90% of their target clinics). SEND, the organisation that was operational in Kailahun, selected eight clinics out of a total sample of 80 for me to visit (which represented 10% of their target clinics). This was the only place where I requested a change to the
16 In total 35 clinics were visited, but four health workers in charge were absent on the day I visited, and out of these four clinics, three had only one health worker assigned to it and in one case both health workers were absent at the same time. 17 With the exception of health workers in control group clinics, where no interventions had taken place. 85 proposed itinerary, as the selected clinics initially included several award winning clinics, which would have biased the sample.
The community monitoring and the non-financial award interventions were part of a large randomised controlled trail. Concern implemented the projects in Tonkolili,18 and the agency IPA collected community-based data to objectively measure the health improvements of the communities involved in the interventions. As a condition of my access to the clinics that were subject to the randomised controlled trail, IPA staff insisted that they selected the clinics where my research could be conducted, to ensure that the clinics from the two treatment groups and the control group that received one additional research visit (for this study) were chosen at random.
The sizes of the four interventions that were examined varied significantly: NMJD’s intervention was the smallest, targeting just ten clinics in Kono District, while SEND, the largest, worked in all 80 health centres in Kailahun District. The two interventions implemented by Concern’s partner agencies targeted 25 clinics per intervention in
Tonkolili District.19 This meant that any similar amount of cases per intervention would always lead to having examined the large majority of all target clinics of the
NMJD project in Kono, but only a small proportion of the clinics targeted by SEND in
Kailahun, see table 2. In the end, the sample size varied from 6-9 cases per intervention due to some minor logistical constraints.
18 The RCT involved two other agencies, Plan International and IRC, which implemented the same two interventions in Bo, Bombali and Kenema Districts. 19 The data collecting agency IPA also collected data in 25 control group clinics, where no interventions took place, and I was asked to also include 6-7 clinics from this control group in my sample. 86
Table 2: Sampling data for this study
Intervention methodology Total amount of Total amount of Percentage clinics targeted by clinics visited for covered by this intervention: this research: research: Participatory Monitoring & 80 8 10% Evaluation Mixed Methods/Quality 10 9 90% Service Circle Community Monitoring 25 6 24% Non-financial awards 25 6 24% (Control group 25 6 24%) Total number of clinics covered by one of the four 140 29 20.7% interventions (excl. control group):
The total number of clinics targeted by one of the four accountability interventions was
140, so by studying 29, the research covered just over twenty percent of all clinics that were subject to one of the four selected accountability interventions. At the time the research was conducted, there were approximately 1020 Peripheral Healthcare Units
(PHUs20) in Sierra Leone, and the total clinic sample of 35 (29 target clinics plus six control clinics) for this study therefore represented 3.4% of all PHUs in the country.
The logistics of reaching each of the 35 clinics that were visited for the field research was by far the biggest challenge regarding reaching sampling targets: All travel was on dirt roads and travelling between clinics could take as long as 3-4 hours. Regardless of the constraints, I felt that satisfactory levels of ‘saturation’ were achieved, which Guest et al define as “the point in data collection and analysis when new information produces little or no change to the codebook” (2006, p. 95). Knowing that saturation is a nebulous concept for which few guidelines exist, I wrote a reflective diary and daily report on every clinic visited, tracking new issues as they emerged and using the rule
20 PHUs: the Sierra Leone-specific term for all small, medium and large public, primary care clinics in the country. 87 of thumb described by Guest et al: when no new issues arise, saturation levels must have been reached.
3.4.2 Conducting interviews
About interviewing in a health context, Nunkoosing writes:
We interview when we want to know something about what another person has to say about her or his experience of a defining event, person, idea, or thing. We choose the interview because we know that the best way to get into the lived experience of a person who has experienced an important health-related issue is to enable the person to narrate that experience. We are interested in the person’s cognition, emotion, and behavior as a unifying whole rather than as independent parts to be researched separately. (Nunkoosing 2005, p. 699)
This study used interviewing as its key method to collect data in the field, as it presented the best opportunity to gain an insight into health workers’ and health service users’ perceptions of the impact the social accountability interventions had. To understand how health workers perceived being part of an accountability intervention, they were asked to recount their experiences of the intervention in which they had taken part during a one-to-one interview. These interviews took place in the office or workroom of the health workers within the clinic, where they would feel fully in control of their privacy, and, I hoped, where they would be at ease in their environment.
The 31 interviews with health workers in charge of a health facility were conducted using interview guidelines (see Annex A). The guidelines were developed based on the research questions and the theoretical framework that was developed prior to the field research. The initial guidelines were then piloted during the scoping visit in September
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2012, and adjusted in advance of the data gathering visits, which were conducted in
November 2013 and May 2014.
3.4.3 Focus group discussions
The focus group discussion methodology was chosen in order to gain an insight into the views and opinions of users of the 29 health facilities that were the subject of one of the accountability interventions.21 It was also chosen for practical reasons; in a group of 6-10 participants it was more likely that there would always be several who had been involved in aspects of the accountability intervention. The decision to select only women for the focus group discussions was driven by two different considerations, practical and methodological: Firstly, the Free Healthcare Initiative
(FHCI) provides free care to specific groups of citizens: pregnant and lactating mothers and children under five (Government of Sierra Leone 2010). Women were therefore the biggest consumers of free primary healthcare (both for themselves and for their children) and thus the best source of information on any changes in the quality of service delivery. Secondly, by selecting only women to participate (and explaining the above reasons clearly to male leaders within the communities), I avoided the potential problem of men assuming the spokesperson role for the community. It also avoided risking the fact that some women might have felt uncomfortable to speak up in front of men about pregnancy, family planning, and other sensitive, health-related topics (Robinson 1999, p. 907).
The small groups of women usually created a non-threatening environment in which health service users could voice their opinion and respond to ideas and suggestions
21 A total of 35 focus group discussions were held: 29 near the selected facilities where a social accountability intervention took place and 6 near facilities that were selected as ‘control’. 89 made by other participants (Krueger and Casey 2001). Participant numbers were limited to eight per focus group, to ensure that all women’s voices could be heard and to facilitate the transcription of the discussion after the event (McLafferty 2004). The focus groups were moderated by me, the researcher, and a translator was at hand to interpret local languages used by the discussants. All focus group discussions lasted between 30 – 70 minutes.
The topics discussed during the focus groups were also guided by a questionnaire (see
Annex A) which steered towards those issues that I had identified as most relevant:
The women’s overall opinion of the accountability intervention, their participation, their perceived benefit and their sense of ownership of it. The groups also explored questions around their relationship with the local healthcare providers and the influence the accountability intervention has had on this relationship. Finally, the plan had been to ask about any ideas the women might have had to use any newly acquired skills/knowledge attributable to the accountability intervention, to address other
Figure 4: The researcher gets ready to start focus group discussion, Tonkolili District, Nov 2013
90 shortcomings in public services in future. In reality, that question didn’t get asked, as newly acquired skills or knowledge was not indicated by any group (see adjusted questionnaire, Annex A).
The questionnaires were guided by the analytical framework of the research, which contained four social accountability components. The fieldwork was designed bearing these four components in mind. In advance of the empirical research stage, an analysis was conducted to identify which data could be collected (academic and grey literature, programme documentation, focus group discussions, interviews at clinic level, at district authority level, key informant interviews in the capital Freetown), and how each of these could yield information related to the four social accountability components. For example, it was clear that details regarding redressing information imbalances and citizen participation would best be obtained through an analysis of the programme documents that could show evidence of the programme designers’ awareness, targeted interventions and/or specific mitigation strategies. For evidence of staff motivation it was important to include such questions in the healthcare staff interviews. Senior staff from NGOs and implementing partner organisations provided insights in each agency’s power and political economy awareness. This analysis narrowed down which information was sought during interviews and focus group discussions (FGDs), and which details were obtained through other sources.
In order to obtain an insight into the effectiveness of the accountability interventions, the field work focused on gathering data that could serve as indicators of the extent to which each of the interventions had achieved its goal. Each intervention aimed to improve healthcare outcomes, by improving the accountability of the healthcare staff.
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As the case study chapters will show in much greater detail, several frequently used discussion topics soon became proxy indicators of basic levels of success.
Where available, I used existing documentation produced by the implementing agencies to corroborate my primary findings. In the cases of the Christian Aid supported programmes this documentation consisted primarily of quarterly and annual reports. For the additional two methods, which were part of a larger World Bank- funded Randomised Controlled Trial, several published papers were available
(Grandvoinnet et al 2015, Hall et al 2014, IPA 2015a, IPA 2015b, IPA et al 2015) – though not until a year after my field research was completed.
3.4.4 Interview data gathered
The research was carried out in three phases, each of which involved a preparatory period followed by a visit to Sierra Leone. The initial visit in 2012 was a scoping visit, followed by two dedicated data collection visits, which took place in November 2013 and May 2014. Table 3 presents an overview of the data collected. The grey shaded section of the table represents data gathered during the pilot study, conducted in
September 2012. Most scoping visit data was disregarded during the overall data analysis, with the exception of three key informant interviews.
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Table 3: Overview of interview and focus group data gathered
Date Facilitating Location PHUs visited Interviewee by type NGO/ (out of total methodology covered by intervention) Sept 2012 Christian Aid- Kailahun 2 2 clinic managers (scoping SEND/ 2 focus groups visit) Participatory 5 key informant/other Monitoring& interview Evaluation Christian Aid- Kono 3 1 clinic manager NMJD/Mixed 3 focus groups Methods- 12 key informant/other Quality Service interviews Circle Nov 2013 Christian Aid- Kailahun 8 (80) 8 clinic managers SEND 8 focus groups Participatory 13 key informant/other Monitoring& interview Evaluation Concern/ CIDA, Tonkolili 18 (75) 18 clinic managers COBTRIP, 18 focus groups OPARD, Pikin- 11 key informant/other to-Pikin interviews Community Monitoring + Non-Financial Award May 2014 Christian Aid- Kono 9 (10) 5 clinic managers NMJD 9 focus groups Mixed Method/ 9 Community Health Quality Service Monitoring Volunteer Groups Circle Independent Freetown 17 key informant interviews
Of the data gathered during the November 2013 and May 2014 visits, the key informant/other interviews included fourteen interviews with Facility Management
Committee members and seven interviews with unpaid staff at clinics (traditional birth attendants and maternal and child health aides). These were treated as separate groups during the data analysis.
The key informant interviews included the District Medical Officers in each of the three districts, a range of other district health authority staff, staff from all the
93 participating NGOs and CSOs, including the directors of Christian Aid, Concern,
NMJD, SEND, COBTRIP and OPARD. Other interviewees included several district councillors, a radio talk show host, the head of Irish Aid, the directors of UNDP,
WHO, IRC and PLAN International in Sierra Leone, and several senior Ministry of
Health and Sanitation (MoHS) staff, including the country’s Chief Medical Officer, the
MoHS Deputy Chief of Policy, three of the Minister of Health’s senior advisors and the MoHS Chief of Primary Healthcare.
3.4.5 Assumptions
In preparation for my field research, I read extensively about Sierra Leone, its health sector and social accountability interventions. The reading of books and journal articles, but also newspaper articles and blogs shaped my expectations regarding the lack of ‘accountable behaviour’ among health workers and the social accountability interventions’ promise to improve it. The literature and newspaper reports on the provision of primary healthcare in Sierra Leone, described a range of common malpractices such as charging for medicine and medical services that should be free, frequent absenteeism of key medical personnel and the uncourteous treatment of patients (Bhandari 2011, IRIN 2012, Maxmen 2013). Amnesty International’s 2011 report stated: “The healthcare system remains dysfunctional in many respects.
Disparities persist between rural and urban maternal health services; the quality of care is frequently substandard, and many women continue to pay for essential drugs, despite the free care policy. As a result many women and girls living in poverty continue to have limited or no access to essential care in pregnancy and childbirth”
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(2011, p. 4). It seemed clear that even though the Free Healthcare Initiative22 (FHCI) was introduced to remove cost barriers and improve access to public healthcare, informal charges for healthcare had never fully gone away, which is why accountability interventions in the health sector were introduced.
My main assumption was that the social accountability interventions I was about to study would have achieved a significant reduction in the types of malpractices that appear to have been common in Sierra Leone’s health sector. Given all of the above, prior to my departure to Sierra Leone for the first field trip for this research,23 I therefore assumed that in this context ‘acting accountably’ would mean that:
Health workers do not charge those entitled to free services for basic medical care. Health workers do not charge those entitled to free care for medicines that are free under the FHCI provision. Health workers are not absent or refuse services during normal daytime hours or outside those hours in case of emergency. Health workers treat patients with curtsey and do their utmost to provide care for them, taking the constraints they face into account.
The questions directed at the health workers and at the healthcare users in the clinics where accountability interventions took place, therefore focused strongly on the impact of each method, taking particular care to probe for evidence (or lack of) of the types of behaviours these interventions sought to eliminate.
22 Free healthcare is targeted at pregnant women, lactating mothers and children under five, who are entitled to a range of free treatments and free medicine designed to treat the most common ailments among that group (malaria, diarrhoea, vomiting, respiratory infections, STIs, etc.). The details can be found in: Government of Sierra Leone, Ministry of Health and Sanitation, 2010, Basic Package of Essential Health Services for Sierra Leone. 23 The first field trip for this research was in September 2012; I conducted my MPhil field research in Sierra Leone in 2003 and visited the country twice for work in 2002. 95
3.4.6 Dealing with contradictory responses
During the field research, healthcare recipients were interviewed close to the clinics they used, which ensured that both healthcare providers and healthcare users had participated in the same accountability interventions.24 By asking both parties similar questions about the social accountability interventions, and about the provision of the free healthcare, it was inevitable that the research would encounter some contradictory responses. However, the level of contradiction was significantly more pronounced than
I expected, which implied that either the health workers or the focus group discussants provided answers that were not entirely truthful or individuals deliberately avoided revealing certain details. Despite the fact that I was prepared for this, given the topic of the research, it was not always easy to deal with. Being aware of the changes in interview responses that white foreigners often elicit (Cilliers et al 2013), I had expected that a certain level of embellishment could occur, but the reality I encountered was much more complex than that (the health system was dysfunctional, staff members were not on payroll, medicines were not delivered in required quantities, etc.). As the case study chapters five, six, seven and eight will show, evidence of improper charging for free healthcare was found in 24 out of 35 clinics, which suggested that in many locations, the accountability interventions had not been very effective in curbing charges for free care. While it was still possible to identify subtle, nuanced differences in the results of the four interventions, due to their different programme designs, it became apparent that the majority of the social accountability programmes had one common problem; most interventions had been unable to curb illegal charging.
24 For some interventions there was no participation from the healthcare users required, but FGDs were nonetheless conducted close to the clinics to gage whether healthcare users had noticed any changes in the way healthcare was being delivered. 96
Once the first few focus group discussions had been conducted it was possible to identify a number of triangulation questions for the discussants to reveal both exaggerations and cover ups of charges levied for free healthcare products.25 Accounts of social science research conducted in Sierra Leone in which authors explicitly deal with similar issues were helpful (Berghs 2011, Fanthorpe 2003, Workman 2011), and led me to consider each response, even when it was clear that its veracity was dubious, as a ‘finding’, rather than an affront. The re-examination of some social science researchers’ first-hand accounts made it clear that uncovering untruths (or discover that information is being withheld) during field research in Sierra Leone is not uncommon:
That is when I realized what was really socio-culturally important was not always initially mentioned because as Ferme (2001) and Shaw (2002) have found, in Sierra Leone what is hidden from outsiders is often more important than what is said. Fanthorpe (2007, 17) agrees and states, ‘Also at work here is a cultural aesthetic of concealment: the idea that overt displays of emotion or intent are morally distasteful and furthermore, court spiritual danger’. (Berghs 2011, p. 259)
Knowing that other researchers had also struggled with having to work out whether the truth was being told and whether interview replies appeared contradictory, made it easier to accept this fact and allowed me to listen more carefully to the responses (all interviews were being recorded so there was never a risk of losing any details). Being confronted repeatedly with the same story justifying charging for medication because a health worker had treated a woman or child for a particular illness, by using ‘cost recovery medicine’ because the free medicine were out of stock, provided fascinating insights into the narratives that were commonly constructed by healthcare workers to
25 I asked what health workers charged for malaria medication or oral rehydration salts, which have been universally free in Sierra Leone for some time, to see if charges were exaggerated, and I asked focus group discussants who maintained that ‘all care was free’, if they paid for injectable medicine (which are extremely popular in Sierra Leone, despite the fact that injections are often unnecessary and at times harmful), which are not included in the basic package of free healthcare products, so they are always charged for. 97 rationalise levying charges for free care. It was not only health workers who commonly used the same story to justify incidences where patients were charged for free care; similar narratives were encountered during key informant interviews too, both among district health management team members and among implementing NGO staff, who were seemingly convinced of the success of their accountability intervention.
These narratives appeared to be a convenient excuse to explain away the reality, that the healthcare system was structurally unable to function properly without the salary
‘top ups’ in the form of illegal charges: the free healthcare system directed all the resources to those on payroll, not taking into account the fact that so-called volunteer workers are an essential part of the support system at primary healthcare facilities, but these volunteers are often unable or unwilling to assist the health workers unless they are paid, as they used to be, prior to the pre-Free Healthcare Initiative (Amnesty
International 2009).
It was not only the health workers’ stories that needed verification. During several focus group discussions it became clear that some health service users felt obliged or compelled to cover up charges that were being levied at their local clinics. In one case, at the end of a tense focus group discussion, the research team driver was quietly cornered by a group of young men from the same community, who had eaves dropped on the conversation, and who wanted him to tell the researchers that the women did not tell the truth. The men explained that they were resentful of the fact that their wives attended the clinic and had to bring “their hard-earned money to pay for services that should be free” (FGD44).26 It transpired that the focus group participants had included
26 All quotes and references that are derived from primary sources are coded. Appendix B provides a full list of all codes related to the interviews and focus groups discussions conducted for this research, 98 a traditional birth attendant (TBA) who was regularly employed at the same clinic, and it was clear that the other women were worried about speaking badly of the health workers in the TBA’s presence, lest she told them of their disclosures. Upon hearing about the revelations, a second focus group discussion was conducted in a nearby village where the women (who attended the same clinic) complained about the charges that were levied. Similarly disjointed focus group discussions took place in three other locations, and in each case the focus group interview was repeated in a different village close to the same clinic, in most cases finding evidence of improper charging.
3.4.7 Paying for interviews
The question whether or not participants would receive payment or some kind of incentive for their assistance during the interviews and the focus group discussions was raised several times during the field visits, usually by the NGO staff who facilitated my field visits, and in one or two occasions by interviewees. During my scoping visit, one of Christian Aid’s partner agencies routinely paid interviewees a ‘transport allowance’ on my behalf without consulting me in advance, while the other agency paid nobody and made it clear that this was their policy.27 It was clear that in preparation for the two subsequent data gathering visits to Sierra Leone a considered response needed to be formulated to deal with the issue. Examining a number of papers on conducting research in Sierra Leone led to the conviction that paying for interviews would lead to attracting the wrong kind of interviewees and therefore ‘playing the poor researcher’ would be in the best interest of the research in terms of getting access to
27 The director of the agency told me how he felt it was against the principles of his agency’s accountability methodology to be offering payment for public consultations (KI001). 99 relevant individuals without having to go through some sort of ‘broker’. This also avoided the ethical debate surrounding the question of whom to pay (all interviewees, including salaried NGO and government health authority staff, or only focus group discussants, who were usually subsistence farmers) and whether paying fuels a dubious system of rewarding for exchanges that should not need any financial incentives, undermining future visitors who may have other good reasons to want to talk to the same people without being willing or able to pay for this.
Bergh’s account of the problems she faced gaining access to the ‘amputee and war wounded’ illustrates that paying for interviews can have complicated and arguably more negative implications than one might expect:
[…] in Sierra Leonean society, a cultural and political system of patronage also exists in every level of society meaning ‘a huge obstacle to reducing corruption’ (EURODAD and CGG 2008, 11). This is no different in the ‘amputee and war- wounded’ community and as Dixon (2002) has described, it is the elites in a community that are seen as enabling relationships to the NGOs and thus must be rewarded for that by weaker members of the community. This complicates issues of ethical and informed consent (Mason 2002), for it is also the educated elites of a community, who liaise with the leaders or local chiefs that act as gatekeepers and give ethical permission for researchers, journalists and NGOs to enter into a community. ‘This naturally causes problems, as all too often contributions end up being used by elites to buy support in patron-client relationships’ (Dixon 2002, 3). Richards (2003, 37) describes how people term this kind of ‘parallel economy’ with goods from humanitarian organizations as ‘the economy of ‘hide and seek’.
(Berghs 2011, p. 260)
During the scoping visit, and again during the actual research, it was quite disconcerting to witness one particular NGO seemingly happy to use a part of their limited budget to pay ‘allowances’ to everybody who was willing to talk to a researcher. This too appeared as if a patron-client relationship was being maintained. It clearly undermined any research being conducted ‘for free’ in the future; once people
100 are aware that money is offered for interviews, the selection of participants shifts from being ‘on merit’ to being ‘as patronage’.
3.4.8 Reflective journal
Sultana’s writing was one of several texts that provided inspiration for the writing a reflective journal.
While it has been argued that reflexivity can result in ‘navel-gazing’, I do not believe that being reflexive about one’s own positionality is to self-indulge but to reflect on how one is inserted in grids of power relations and how that influences methods, interpretations, and knowledge production (cf. Kobayashi 2003). It is also implicated in how one relates to research participants and what can/cannot be done vis-à-vis the research within the context of institutional, social, and political realities. As such, it is integral to conducting ethical research. (Sultana 2007, p. 376)
Throughout the research visits I kept a reflective journal in order to record thoughts and feelings that were relevant to the research, to my position as a white western female conducting research in West Africa, and, most importantly, to record responses to some of the more challenging findings that were obtained on a daily basis. The reflective journal was complimented by a second journal of short reviews written about each clinic that was visited and the interviews that were conducted in and around it.
This ‘connected up’ the personal impressions of the health workers’ interviews, focus group discussions and any other interviews conducted in the same locations. It allowed me to air subjective impressions and include speculations as to ‘what is really going on and why’. Writing the two journals was a cathartic experience and its output will be used to supplement the analysis of the data.
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3.4.9 Feeding results back to research participants
The seminar on research ethics, which I attended at the University of Limerick in May
2012, impressed on all students the importance of feeding back the research to the participants, as much as this would be possible. While it is rarely feasible to revisit each of the individual interviewees, it was in my case possible to give participating
CSOs and NGOs feedback about the research findings. The feedback sessions took a variety of forms: from a debriefing with a CSO director during a car journey to more formal meetings with a range of staff members and participants of the research.
Contacts established during the research period in Freetown led to an invitation to give a briefing on the research to ministerial advisors of the Minister of Health in State
House. The Irish Ambassador to Sierra Leone made a meeting room in the embassy available to hold a research feedback session, which brought together representatives from all the international agencies that had been involved in the research (Christian
Aid, SEND, NMJD, World Bank, Concern, IRC, and PLAN) and a number of interested NGO and CSO staff members whom I had been in contact with for the research.
Given that the research was focused on methodological differences in social accountability interventions, it was felt that feedback sessions at this level (as opposed to feedback to individual interviewees at community level) were appropriate. The majority of the NGOs that had implemented the interventions were able to attend at least one of the feedback sessions and most responded positively to the events (see appendix C for a full list of all feedback sessions), requesting to be emailed further data, which was sent.
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The collaboration with Christian Aid included a commitment that a report on the field research findings was to be drafted, which would be ‘practical rather than academic in tone’. This report was produced shortly after the final field visit. A similar report was also produced for Concern staff, who were at that time implementing further social accountability interventions. According to the Concern health advisor, the research report led to a number of changes in the Concern programme design.28
In addition to providing feedback to research participants in Sierra Leone, I also led the organisation of a workshop with Christian Aid, to further disseminate the findings of the research. The event, titled “Governance, Accountability and Citizen
Empowerment: A learning workshop” was held in Dublin in June 2014 and was attended by over 60 participants from major Irish NGOs, universities and Irish Aid.
The speakers included Alina Rocha Menocal and Fletcher Tembo from the Overseas
Development Institute in the UK, as well as the director of SEND foundation, the
Christian Aid governance advisor for Sierra Leone, and the head of governance and accountability for Christian Aid Ireland. Other speakers included representatives from the Ethiopian Social Accountability Programme, the governance advisor for Irish Aid
Ethiopia, the director of the Civil Society Budget Advocacy Group, Uganda and an
Irish academic who presented her research on governance in Burundi.
The findings of this research have further been disseminated through the publication of an article titled ‘When free healthcare is not free. Corruption and mistrust in Sierra
Leone’s primary healthcare system immediately prior to the Ebola outbreak’, published in the journal International Health, in May 2015, and through the
28 After my report was received, Concern staff conducted additional facilitators’ training which emphasised the content of the ‘Community Compact’ in great detail. It was made clear that facilitators had to work towards genuine commitments of change from both the health workers and the community, ensuring that the Community Compact contained commitments that were actual solutions to the problems raised during the discussions. 103 presentation of two conference papers, presented at the Development Studies
Association of Ireland conference in Dublin in November 2015, and at the World
Humanitarian Studies Conference in Addis Ababa, in March 2016.
3.4.10 Ethics and consent
Before I conducted the first scoping visit to Sierra Leone, I attended a course on ‘ethics in social science research’ at the University of Limerick, and subsequently conducted a full ethics review of the proposed research project. Since the study investigated human participants, consideration was given to the possible ethical dilemmas that may occur.
The research was of a potentially sensitive nature, it was therefore vital that ethical approval was sought. The University of Limerick’s guidelines for ethical research stress that the research must be conducted responsibly and that the participants are protected with regards to matters of privacy, anonymity, consent, and the storage of data.
The guidelines seek to mitigate against harm done towards participants and ensure the research is conducted professionally. The research ethics course stressed that all participants were told the truth about what the researcher expected of all participants and what the research is expected to achieve. During the research, these details were provided to all research participants and verbal consent was obtained from all,29 while written consent was obtained from the health workers who participated. The ethical research guidelines were adhered to by the researcher and those who temporarily assisted her. Ethical approval for this research was granted by the University of
29 During the scoping visit a consent form was used during focus group discussions and discussants had been asked to sign it, but this created more confusion than it reassured people, as the overwhelming majority of women participants were illiterate. 104
Limerick Arts, Humanities and Social Sciences Ethics Committee in June 2012 – reference number FAHSS REC 649.
3.5 Data analysis
The information obtained in the 2013 and 2014 data gathering trips to Sierra Leone provides the core data for analysis for this study. The data for this study was obtained from key informants, interviews with health workers who participated in the social accountability interventions and during focus group discussions with women who regularly used the clinics where the interventions had taken place.30
The first data gathering trip yielded over seventy recordings. It therefore soon became clear that a systematic approach was needed to analyse all the data and to make sense of the rich detail that was contained within each of the data sources. In order to do so, I decided to use qualitative data analysis software, NVIVO10, engaging first in training to be able to use the software correctly and to its full potential.
I decided to use a qualitative content analysis method to ensure that the different themes that emerged during the research would be objectively represented. It allowed me to code the audio files of the data gathered without first having to transcribe the interviews. Through this method, I retained an acute awareness of the situation under which every interview took place, being repeatedly immersed in the audio files containing the data, which includes the ambient noises, the pauses and the silences as much as the words that were spoken (Wainwright and Russell 2010, p. 3). I drew on
30 With exception of a small group of clinics which were the ‘control’; no intervention took place in these six clinics. 105
Krippendorff (2004a, 2004b) and used a system of ‘coding phases’ to first review the audio files, then code all relevant sections of the interviews and focus group discussions according to what was said, before grouping responses together to create emerging themes. The qualitative content analysis method, which usually uses individual themes as the unit for analysis, rather than the physical linguistic units, e.g., word, sentence, or paragraph (Zhang and Wildemuth 2009, p. 3), especially appealed to me: it allowed room for the rich language in which many concepts were described to remain at the forefront (e.g. “the president is tired” was one way an interviewee described how she was told that the state-backed free healthcare medicine had run out).
The audio files were reviewed several times subsequently to ensure that all information regarding these themes was picked up correctly, and after that, a series of revisions and merges of the codes took place to structure the themes into hierarchies, and to ensure that all the sentiments expressed in the data were captured according to prominence and relevance to each other. To provide an overview of the codes that were generated during the data analysis, Annex D contains the final round of codes.
3.6 Conclusion
This chapter has demonstrated the strategy and the process of data collection for this study. It started with the operationalising of the analytical framework and outlined why a comparative case study methodology was chosen as the research method. The second half of this chapter has also given some insights into the practical challenges faced during the gathering of the research data. Finally, it has detailed the data analysis strategy to demonstrate how decisions for reporting certain results were made. 106
The next chapter provides an overview of Sierra Leone’s recent history, a brief summary of the post-war reconstruction efforts and the ongoing decentralisation that affects the management of health services throughout the country. The chapter will also provide an in-depth look at the introduction of the Free Healthcare Initiative and the subsequent challenges that were the catalyst for the accountability interventions in the health sector which are the topic of this thesis.
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Chapter 4 - Sierra Leone’s challenging operational
environment
4.1 Introduction
In the last chapter I outlined the reasons for conducting the field research for this study in Sierra Leone, and more specifically in Kono, Kailahun and Tonkolili Districts. This chapter will describe the operational environment in which the four social accountability interventions took place. The chapter will start with a brief overview of the key events in Sierra Leone’s recent political history. Section 4.3 will examine some of these in more detail to demonstrate how events from the past have shaped Sierra
Leone’s political and administrative system and culture. Section 4.4 will provide some background about the introduction of the Free Healthcare Initiative and show how the accountability interventions under study are directly related to the introduction of the free healthcare and the subsequent implementation problems. Section 4.5 explains how
Sierra Leone’s civil society, which became involved in the monitoring of the free healthcare by the end of 2012, has long faced its own challenges and has therefore not always been able to make the contribution to accountability that could have been hoped for. Section 4.6 concludes.
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4.2 Setting and historical context
4.2.1 A brief overview of key events of Sierra Leone’s history
Each country has its own distinct history that charts how current boundaries, political systems and relationships were shaped by events of the past. With regards to Sierra
Leone, Kilson describes how at the end of the eighteenth century:
[…] the first step was taken toward establishing a modern governmental system capable of sustaining both commercial and cultural relations with the western world. In 1787 a group of British businessmen, philanthropists, and missionaries, concerned partly with ending the slave trade and with removing impoverished freed slaves from the streets of London, arranged for the settlement of several hundred freed slaves in the peninsula area of Sierra Leone. (Kilson 1966, p. 1)
From then on, British engagement gradually grew larger. In the early 19th century the area around present-day Freetown became a Crown Colony, and in 1896 the British established a protectorate over Sierra Leone’s hinterlands (Alie 1990, p. 126, Allan
1968, p. 305, Kargbo 2006, p. 38).
The Protectorate and the Crown Colony were ruled as separate entities with separate legal systems until a new constitution was drawn up in 1947, bringing the two together. According to Fyfe, the draft constitution was met with resistance from the
Colony, which was populated by Creoles, the descendants of freed slaves, who were
British subjects, unlike those of the Protectorate. At that time 90% of the population of the Protectorate was illiterate, which illustrates the lack of British investment in the
Protectorate inhabitants (Fyfe 1962, p. 174). By 1951 the new constitution was adopted, partly in response to the demand from the newly formed Sierra Leone
People’s Party (SLPP), led by Dr. Milton Margai. The SLPP at the time was described by Kilson and Fyfe as a protectorate party (Fyfe 1962, Kilson 1966), but one that was 110 predominantly supported by the elite of the hinterland, the chiefs and paramount chiefs
(Kilson 1966, pp. 190-191). The nascent SLPP widely condemned popular uprisings against perceived unfair tax collections in 1955 and 1956, which led to looting and damage to wealthy chiefs’ property throughout the protectorate. Despite siding with local administration, which was considered responsible for a corrupt tax administration and “the abusive exercise of customary rights to tribute and communal labor” (Kilson, p. 189), the SLPP was on course to becoming Sierra Leone’s dominant political force.
By the middle of the 20th century, the decolonisation of the African continent had started. In 1954, the leader of the Sierra Leone’s People’s Party, Sir Milton Margai, became Sierra Leone’s Chief Minister. Unlike many other British colonies in Africa,
Sierra Leone’s independence was not preceded by a violent independence struggle.
Milton Margai negotiated the transfer to independence and Sierra Leone officially became a sovereign state in 1961 (Fyfe 1962, p. 178). Margai became Sierra Leone’s first Prime Minister and was re-elected during the first post-independence elections in
1962 (Allan 1968, pp. 308-309). Milton Margai is generally considered to have been an effective Prime Minister, having successfully steered his country through its first post-colonial years. His cabinets and even the new army’s top brass reflected Sierra
Leone’s mix of ethnicities (Hayward 1984, p. 22).
Upon Milton Margai’s death in 1964, his brother succeeded him and the first signs of a deterioration of governance became apparent. Albert Margai favoured individuals from his own Mende tribe within his political circle and in the armed forces (Hayward
1984, p. 23). In the run up to the 1967 elections, Albert Margai’s SLPP attempted to introduce a one-party system, ban opposition newspapers and encourage ballot rigging
111 in the elections. The undermining of the opposition only seems to have strengthened it; the more urban based opposition All People’s Congress (APC) won the 1967 general elections (Allan, 1968, pp. 313-323; Hayward, 1984, pp. 24-25). Sierra Leone became one of the first African nations to bring an opposition party to power through the electoral process (Hayward 1984, p. 21), but the euphoria did not last long. Within hours of APC’s leader Siaka Stevens’ swearing in, the army staged a coup. This coup was followed by a counter-coup, and led to a period of interim rule. Eventually, just over a year after his initial victory at the ballot box, Siaka Stevens was returned to power following another coup (Allan, 1968, p. 329).
4.2.2 The Stevens and Momoh years
From the outset of his contested reign, Siaka Stevens had to battle to remain on top
(Reno 1995, pp. 79-103), working hard to control the country’s elite, while the actual running of the country suffered: “The task of heading off challenges took precedent over building state institutions […] making it even more unlikely that spending would produce anything resembling greater state ‘capacity’” (Reno 1995, p. 87). The patrimonial leadership style (Kpundeh 1994, p. 140, Smith 1997, p. 58) that Albert
Margai introduced was embraced by Stevens and applied in greater form. Smith argues that “[…] the APC, under Siaka Stevens and Joseph Saidu Momoh radically transformed state corruption. It was transformed from a simple chaotic activity to a well-organized systemic activity: an activity where contracts were being rigged, decisions bought and sold, elections corrupted, and political rivals threatened and physically coerced” (1997, p. 58). Stevens made several major changes to Sierra
Leone’s constitution in his 1968-1985 tenure. In 1971 Sierra Leone was declared a
112 republic and Stevens became its President. In 1978 Sierra Leone became a one-party state. Stevens retired in 1985 and appointed Major General Joseph Momoh as
President: an army officer whose version of continued patrimonialism was, according to Smith (1997, p. 60) “distinctively ethnic in origin and parochial in nature.” Momoh remained President (surviving a coup plot in 1987) until he was ousted in a coup in
1992, during the civil war. In total, the All People’s Congress was in power for 24 pre- war years.
4.2.3 Economic collapse
The 24 years of APC rule (1968-1992) coincided with a period of unprecedented economic decline in Sierra Leone, culminating in 1987 in the declaration by President
Momoh of ‘a state of economic emergency’. The 1973 oil crisis meant that oil imports quadrupled in price. Prices for Sierra Leone’s cocoa and palm kernels decreased; corruption and complete economic mismanagement resulted in a reduction of exports and tax earnings; terms of trade worsened and inflation soared (Luke and Riley 1989, p. 138, Reno 1995, p. 61, Zack-Williams 1990). By the 1980s, currency shortages were common, and civil servants received some of their salaries in rice. The smuggling of diamonds, which occurred initially with the tacit tolerance and later active involvement of Sierra Leone’s elite, including the President, deprived the state of millions of US dollars in tax revenue (Reno 1995, pp. 104-129).
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4.2.4 The civil war
By the time a rebel army invaded in 1991, Sierra Leone had largely stopped functioning as a state. Basic state services such as health and education had all but ceased to be provided outside of the capital Freetown. Rural Sierra Leone had become an area where uneducated and unemployed youth had no opportunities. Scholars would later identify Sierra Leone’s eastern border region as an area that bore many of the hallmarks of being prone to contestation, harbouring a large population of angry young men who had little else to do but join the conflict (Blattman and Miguel 2010, Collier and Hoeffler 1998, p. 61, Kandeh 1999, p. 351, Smith 1997). However, the initial rebel offensive came largely as a surprise. Abdullah wrote, in retrospect, “When the
Revolutionary United Front/Sierra Leone entered Kailahun District on 23 March 1991, few people took them seriously or realised that a protracted and senseless war was in the making” (1998, p. 203). Keen describes the events as follows:
The war in Sierra Leone was ignited in March 1991 when a small band of rebels, supported by Liberian rebel Charles Taylor, attacked from Liberia. But it was underlying resentments inside Sierra Leone that turned this relatively small incursion into a conflict that displaced close to half the population. (Keen 2003, p. 67)
It is estimated that between 50,000-75,000 people were killed during Sierra Leone’s civil war, and many thousands were injured in battle and in attacks that left victims dead or injured, raped, brutalised or with limbs hacked off (Human Rights Watch,
2002, UNOCHA 2002). In the 11 years of war, the country experienced two coups, a period of military rule, and even a period when the rebel Revolutionary United Front
(RUF) forces combined with the Sierra Leone army to gain control of the country.
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4.2.5 Civil war narratives
The report published by Sierra Leone’s Truth and Reconciliation Commission blamed successive political elites for creating an environment in which a civil war could easily break out:
Successive political elites plundered the nation’s assets, including its mineral riches, at the expense of the national good. Government accountability was non-existent. Institutions meant to uphold human rights, such as the courts and civil society, were thoroughly co-opted by the executive. This context provided ripe breeding grounds for opportunists who unleashed a wave of violence and mayhem that was to sweep through the country. Many Sierra Leoneans, particularly the youth, lost all sense of hope in the future. Youths became easy prey for unscrupulous forces who exploited their disenchantment to wreak vengeance against the ruling elite. The Commission holds the political elite of successive regimes in the post-independence period responsible for creating the conditions for conflict.
Final Report of the Truth & Reconciliation Commission of Sierra Leone, Vol. 2 (2004), paras 13-18, p. 27
Different narratives exist to explain the causes of the civil war. Paul Richards’ seminal book ‘Fighting for the Rainforest’ is probably the best known, but other academics such as Richard Fanthorpe, William Reno, Jimmy D. Kandeh, Lansana Gberie, Krijn
Peters and Paul Jackson have also contributed greatly to our understanding of the causes of the Sierra Leone conflict. Richards’ war narrative focuses strongly on the power structures of rural Sierra Leone. He argues that the living conditions of young rural men in the agrarian border region with Liberia were a determining factor in the civil war. Richards is not the only one who noted that successive governments provided no opportunities for its citizens, nor, least of all, for its youth. Hanlon argues:
At independence from Britain in 1960, Sierra Leone was extremely poor, had a literacy rate of only 7.7 per cent (World Bank 2002). […] By 1986, education spending was one-sixth of what it had been five years before; teachers were often not paid, and President Momah declared that education was a privilege, not a right. In Sierra Leone, privileges went through the patrimonial system, and young people felt increasingly excluded. (Hanlon 2005, p. 1) 115
There were several reasons for the disenfranchisement of rural young men from the south-east of the country. The ruling APC party deliberately neglected the southern and eastern districts, while it favoured the north, home to the Temne and other ethnic groups which APC considered its powerbase (Kandeh 1992). Richards believes that the chiefdom system had a far greater impact on the young men from the eastern districts; all powerful chiefs used bonded labour until well into the 20th century, leaving many young men poor, lacking resources and unable to marry. It was perhaps no surprise many readily joined the Revolutionary United Front when they came across the border preaching change (Richards 1996).
The ‘diamond narrative’ is inextricably linked to Sierra Leone’s civil war. However, there are few historians or academics who believe that the quest for diamonds should be perceived as the cause of the conflict. Fanthorpe, a well-known Sierra Leone expert, is among many authors that criticised the international community for focusing too heavily on the diamond narrative (2001, p. 366). Keen, too, notes with disapproval that
“Sierra Leone’s Permanent Representative to the UN, Ibrahim Kamara, told the UN
Security Council in July 2000: ‘The root of the conflict is and remains diamonds, diamonds and diamonds […]’” (Keen 2003, p. 67). While few scholars dispute the fact that the struggle for the control of lucrative diamond producing areas both fuelled and prolonged the war, few would argue that access to diamonds was its cause. A report by the NGO CARE International published in 2002 concluded: “Contrary to popularly held views that ‘the diamond issue’ was the root cause of the war, more evidence points toward issues like corruption, poverty and bad governance, and the corresponding need for food security, justice, and the creation of democratic mechanisms capable of protecting the rights of ordinary citizens” (2002, p. 3, as cited in Keen 2003, p. 69). A World Bank study comments that: “It is significant that 116 everyone we spoke to talked of the collapse of institutions as the root cause of the civil war, not diamonds. […] The collapse resulted in a signal failure to provide public services equitably and an almost total failure to maintain a just dispute resolution system” (2003, p. 5). What is true is that the rebels’ control over diamond fields enabled them to access weapons and supplies and so helped to prolong the war
(Abraham 2001, Fanthorpe 2001).
4.2.6 The post war years
Sierra Leone’s war was declared over in 2002. At this point, rebel leader Foday
Sankoh had been in detention for some time, the peace accord was signed, large numbers of fighters were ready to disarm and the slow road to recovery started (Keen
2003, Reno 2003). Elections were held just months after the end of the war, and it was no surprise that Ahmad Tejan Kabbah of the SLPP won. Kabbah had won the 1996 elections that were meant to halt the civil war, but he had been deposed by the army within a year of his victory (Zack-Williams 1999). The vote was decisively anti-APC, the party that had been at the helm during the 24 years of pre-war decline.
The post-civil war years saw aid flooding in. Between 2001 and 2006 the country was the largest per capita recipient of foreign aid in the world (OECD 2010). Institutions such as the judiciary, the army and the police were reinstated with significant donor support. Schools and hospitals were rebuilt. The goodwill from abroad was largely met by greed and opportunism from the new SLPP government. While there were some successes, especially in the rebuilding of education and health infrastructure, over time it became clear that Sierra Leone’s new government lacked the commitment to really
117 change the status quo and tackle corruption in the civil service. The International Crisis
Group noted:
Too often the government, attracted by extra funds, has signed up to projects it was clearly unprepared to implement adequately, or which were not immediate priorities. Inadequate commitment to projects, resulting in misuse of the money, has been at the root of much of the corruption that has characterised post-war institution building. Corruption in the civil service is evident, even without reliable sector statistics. A recent survey of the provincial branches of the health and agriculture ministries, for example, found 162 ghost (or dead) workers on the payroll; an assessment of the senior civil service in 2005 discovered that salaries were being paid to 236 persons when there were only 125 at those grades.
(International Crisis Group, 2007, p. 9)
By the time the next elections were held, in 2007, the ruling SLPP had obtained a reputation for corruption and there was in-fighting over its presidential candidate. The incumbent party spent large amounts of exchequer funds on their presidential campaign, and hired thugs to stir up trouble and disrupt the opposition’s election rallies. The opposition did the same. The election results that show political loyalties polarised along ethnic and regional lines (Christensen and Utas 2008, International
Crisis Group 2007, 2008, Kandeh 2008). Despite all of the underhand tactics, the
SLPP lost its grip on power in 2007, and Ernest Bai Koroma became APC’s first post- war President.
Commentators believe that SLPP lost because of its dismal governance record, and due to the formation of the People’s Movement for Democratic Change (PMDC) party, a second Mende dominated party led by a disgruntled Charles Margai, grandson of
Sierra Leone’s second President, who had expected to be chosen as SLPP presidential candidate. The PMDC split the Mende vote and attracted ballots from many
118 disgruntled southerners who had expected a windfall after the SLPP came to power, but had seen the elite take all the spoils. Kandeh noted:
The [2007] elections were referenda on the SLPP, which lost both the presidency and the legislature because its rogue leadership squandered the goodwill of the public, misappropriated donor funds with impunity, and failed to deliver basic social goods and services. (Kandeh 2008, p. 603)
Yet again, Sierra Leone made history with a relatively peaceful change of party in power, joining the then small group of African states which had achieved such turnovers.
4.2.7 Koroma in power
On the surface, Koroma’s first term in office appears to have been more focused on achieving broad-based development for the whole of Sierra Leone, with the completion of the Bumbuna Hydroelectric Dam in 2009 and the introduction of the
Free Healthcare Initiative in 2010. However, it didn’t take long for the first signs to emerge that the party was also reverting to old ways. Quoting a British Strategic
Conflict Assessment Report, Gebrie notes its concern about: “[…] significant regression into inter-ethnic and inter-political party relationships in the country under
Koroma” and adds that an Africa Confidential report also expresses “Concerns about corruption in the country have also heightened under Koroma” (Gebrie 2010, p. 1). His report further notes:
[…] observers have suggested that as many as 200 high and midlevel professionals from the Southern and Eastern provinces, mostly Mende, were sacked within a year of Koroma coming to power, many of them without regard for official procedure. They were replaced by people almost entirely from the north of the country, in particular Bombali District (the president’s home). 119
(Gebrie 2010, p. 5)
This trend was to typify APC rule. Writing about Sierra Leone’s heavily donor supported security sector, Albrecht and Jackson observed about the post 2007 era:
Progressively, the rules of the neo-patrimonial governance system were again being enforced, with the result that state institutions, including those of the security sector, were governed by this logic rather than by principles of democratic governance.
(Albrecht and Jackson 2014, p. 104)
It was perhaps surprising that the 2012 elections were won by the incumbent, Koroma.
Commentators blame the SLPP’s choice of a front runner, the civil war era coup plotter Julius Maada Bio, as a bad decision, while others believe the SLPP simply didn’t convince the electorate outside of their own ethnic Mende region that they had a new vision that all of Sierra Leone should want to be a part of (Kamara 2012). In advance of the elections, critics were sceptical of Koroma’s decision to reappoint his controversial Vice President, Samuel Sam-Sumana, as a running mate, who had been implicated in two high level corruption cases31, but given that Sam-Sumana hails from
Kono, the election’s most important swing state, the gamble seems to have paid off
(Pratt 2012).
31 In one case, Sam-Sumana’s staff had been filmed soliciting bribes on his behalf for the illegal sale of timber, which was caught on camera for the Al Jazeera programme Africa Investigates: https://www.youtube.com/watch?v=DDisMlwlSgk 120
4.3 Sierra Leone’s governance and administrative constraints
Here I will provide a brief overview of the operational environment in which the four interventions were implemented. It provides details about Sierra Leone’s decentralisation process, which has taken place since the end of the civil war, and which has had a profound effect on the management and oversight of primary healthcare services at a local level. It briefly highlights the influence Sierra Leone’s politics has on its governance and administrative capabilities, which continues to be hampered by political economy challenges leading to underinvestment and capacity constraints.
4.3.1 Decentralisation and the establishment of local councils
The development challenges facing Sierra Leone today have a long legacy. The country’s postcolonial history has been marked by exceptionally poor governance and development results. Even in the 1960s and 1970s, growth of per capita incomes was barely positive, and it turned negative during the 1980s. The political economy of development was characterized by a strong urban bias and the marginalization of wide sectors of the population, especially youth.
(Larizza et al 2014, p. 177)
When Sierra Leone emerged from its 11-year civil war, it was left with a governance legacy characterised by a highly centralised and dysfunctional national administration; government effectiveness ranked as among the worst in the world (Kaufmann, Kraay, and Mastruzzi 2006). Kanu describes how in 1972, under Siaka Steven’s leadership, existing district, town and city councils were abolished and the country’s rural governance was merged with the central government’s provincial administration, while town governance reverted to management committees, controlled by central political authorities. The lack of actual governance, a lack of investment in basic services for citizens, which many believe contributed to Sierra Leone’s descent into chaos, has its
121 roots in this recentralisation. As Kanu notes: “[…] even before 2004, local district government gradually declined until only a remnant of government remained at that level. The few remaining staff provided very little service to the public” (2009, p. 29).
In the immediate aftermath of a civil conflict, governments and international donors alike often recognize the necessity to rapidly rebuild the public services for the population, as a goal in itself as well as an entry point for peace building (Brinkerhoff
2005, Rushton 2005). In a bid to introduce a new system that would be able to restore services and governance to the entire country, Sierra Leone’s post-war government led by Tejan Kabbah’s SLPP committed itself to decentralization. A World Bank report that reflects on its staff’s experience during the 2003-2007 period, in which the agency provided two large public sector support programmes, describes how the decision was made to push for rapid decentralisation:
Significant effort was made to increase spending for primary services, especially education, health, and agriculture. However, [Ministry of Finance, (MoF)] and the donor agencies were dismayed by the pervasive leakage of resources, which was documented in the annual Public Expenditure Tracking Studies (PETS) conducted by [the Economic Policy and Research Unit of the MoF]. PETS 2002 found that less than 10 percent of essential drugs said to be delivered at the central government level could be verified by district medical officers (DMOs) and less than 5 percent could be verified by peripheral health units. […] It was clear to the MoF that something must be done to reduce the leakage of resource between the center and the frontline. Partly out of frustration with the slow progress in reforming a centralized and corrupt public financial management system, MoF became an unusual champion of fiscal decentralization. (Zhou 2009, p. xviii)
The first years after Sierra Leone returned to peace saw rapid change in governance structures; one of the most significant changes was the re-establishment of elected local councils. From the time Siaka Stevens abolished local councils in 1972 (Sawyer
2008), local governance was the responsibility of Sierra Leone’s chiefs, whose rule was heavily associated with ineptitude and corruption.
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Sierra Leone’s chiefdom system has been in place since the country’s pre-colonial times. Broadbent summarises the formalisation of the chieftaincy system as follows:
Governance of rural areas was administered through local chiefs whom the British administration subsumed under their authority. The system remained unchanged until their formal constitution through the Tribal Authorities Act 1937, the Chiefdom, Chiefdom Treasuries Act 1938 and the Tribal Authorities (Amendment) Act 1964, in which the roles of village, section and paramount chiefs were stated. Essentially, this legislation enshrined the chieftaincy as part of the Constitution, guaranteeing each paramount chief a council consisting of the paramount chief, sub-chiefs and ‘men of note elected by the people’.
(Broadbent 2012, p. 7)
Jackson explains that the chieftaincy system continues to be led by 149 paramount chiefs, each of whom is elected for life from hereditary families known as ‘ruling houses’. Each chiefdom is divided into sections, each governed by a section chief, and the villages that make up each section are led by a village headman (2006, p 98). Many of Sierra Leone’s civil war-narratives focus heavily on the negative role that chiefs played in the marginalisation of youth in advance of the conflict (Archibald and
Richards 2002, Richards 2005, Fanthorpe and Maconachie 2010, Jackson 2005, 2006).
Chiefs imposed excessive taxations, severe punishments for minor misdemeanours and denied support to young men who wanted to access land to marry and start a family.
Chiefs’ links to the corrupt diamond trade and the selling of their communities’ land to mining companies for personal gain rather than the community’s interest have also been widely documented, as has many communities’ distrust of chiefs in the handling of post war aid goods (Fanthorpe and Maconachie 2010, Jackson 2005, 2006, Sawyer
2008).
The objective of the decentralisation process was to establish formal state institutions in every part of Sierra Leone and bring development resources to every part of the country - without it being co-opted for political means by the chiefdom administration 123
(Acemoglu et al 2012, Edwards et al 2014, Sacks and Larizza 2012). The World Bank funded a large scale local government reform programme arguing that “The postconflict context presents the opportunity to be bold. It gives Sierra Leone the opportunity to reform or re-invent institutions that will best address the country’s needs and characteristics” (2003, p. 1). The Local Government Act was enacted in
March 2004 and inaugural local council elections were held three months later. This led to the establishment of 19 new local councils nation-wide with the mandate to coordinate the development of the localities (Edwards et al 2014, p. 1).
A governance reform process that started so promisingly soon ran into political resistance: rather than dismantling the outdated chiefdom system at the end of the war, when there was a lot of political appetite for it, President Kabbah resisted and kept the old system in place. This led to the emergence of two parallel systems: the chieftaincy and the local councils. Sierra Leone is divided into 149 chiefdoms, each ruled by a single paramount chief, considered the top authority in his or her chiefdom. The councils are categorized in three types: city, town and district councils (Zhou 2009,
29). The decision not to abolish the chieftaincy system was generally considered a political move designed to allow the ruling elite to continue to exert power in the rural areas through their personal and political connections with the chiefs. This has allowed the continued facilitation of vote buying among each party’s own ethnic groups.
The 2007 change of political party in power did not bring clarity to the governance system, if anything, it made things worse. Under APC rule, the protection of the chiefdom system was reconfirmed by the adoption of the Chieftaincy Act of 2009. The act institutionalized the power of traditional authorities, acquired during the colonial era. Under the law, the central executive has effective leverage over the chieftaincy,
124 because it plays an important role in the election and removal of paramount chiefs
(Srivastava and Larizza 2011, p. 150). Simultaneously, the APC government rowed back on its support for the local council system, as Edwards et al explain:
A formal National Decentralization Policy (NDP) was launched in April 2011, calling for the full devolution of human resource and payroll management to local councils by the end of 2016. However, these attempts to establish a functioning local government system coincided with the revitalization of traditional authorities. The NDP, for example, describes a local council as the “highest development and service delivery authority” in its locality, not the “highest political authority” as stated in the LGA of 2004. The explanation at the time was that the local councils are for development while the traditional authorities are for law and order. (Edwards et al 2014, p. 2)
The contradictory policies introduced by the APC government sent out mixed messages about its intentions for local governance and development. Robinson presents the government’s efforts “to re-legitimize the chiefs as a conscious effort to create a dysfunctional and quite incoherent set of institutions with local councils under-resourced, dependent on central state for funding and in conflict with the paramount chiefs or other elements of the chieftaincy institutions” (Robinson 2010 as cited in Larizza and Glynn 2014, p. 242). As a result of the parallel system, confusion continued. Labonthe writes: “Decentralization remains a fragile, partially completed process that continues to foster competition among and within local councils and chiefdoms for access to peacebuilding resources and allocation authority, seldom to the benefit of local communities (2011, p. 92).
To this day, the decentralisation process is ongoing, though progress has slowed down considerably. A review of progress by World Bank staff notes with some frustration:
“While it is clear that Sierra Leone has made great progress in implementing its decentralization law and policy, there remains considerable room for continued
125 improvement” (Yilmaz and Weedon 2014, p. xi). The impact on public sectors is significant:
Incomplete devolution affects the health sector significantly, particularly where the accountability chains are becoming more complex because of this incomplete devolution process. Responsibility for hiring health workers and procuring drugs, for example, continues to rest—in practice—with the central Ministry of Health and Sanitation, even though by law these responsibilities are supposed to be devolved to district governments. In practice, supervisory responsibilities lie with district governments, which lack the power to reward or sanction staff meaningfully.
(Grandvoinnet et al 2015, p. 234)
The political meddling that led to the parallel governance structures is not helping the bid to strengthen local governance. With a lack of clarity among citizens who should take responsibility for the delivery of a range of local services, it is difficult to see how demand for responsive governance among citizen groups and civil society organizations can be strengthened. Yilmaz and Weedon note:
An important component in addressing these challenges will be untangling the political economy of Local Councils, Ward Development Committees, and traditional authorities, with the goal of clarifying roles and responsibilities across the local public sector and reinforcing lines of communication from citizens to decision-makers.
(Yilmaz and Weedon 2014, p. x)
This, the same report seems to suggest, has led to a catch-22 situation: “[…] it seems that the continued centralized line ministry control over local services has contributed to the relative ineffectiveness of the public sector in Sierra Leone” (2014 p. 4). The political establishment conveniently hides behind the argument that if local governance structures are not strong enough, it would be unwise to push ahead with the outstanding steps in the decentralisation process, such as the devolution of greater fiscal and human resource decision making. However, if local councils remain starved
126 of funds to develop local services and capacities, they will never be deemed strong enough for these final steps to be taken.
4.4 Civil society‘s role and capacity in post war Sierra Leone
This section of chapter four will illustrate that many of the underlying political economy challenges that characterise Sierra Leone’s public sector are also found within the non-governmental sector. While community based organisational life in
Sierra Leone is rich and diverse, it is the least accountable sub-section of civil society which has been involved in accountability interventions, with decidedly mixed results.
Sierra Leone has a rich history when it comes to grassroots level associational life. A report by the organisations Campaign for Good Governance and Civicus traces a diverse range of groups back as far as 1851, they list:
[…] trade and artisan related organisations such as the Sierra Leone Agricultural Society, Sierra Leone Farmers Association and the Sierra Leone Mercantile Association. Professional associations included the African Civil Servants Association and the Sierra Leone Bar Association. Organisations that emerged directly to make civic demands on authorities included the Negro Progressive Society and the Rate Payers Association. The mobilisation efforts of citizens to oppose the introduction of the Criminal Code led to the formation of the African People’s Union.
(Campaign for Good Governance and Civicus 2014, p 15)
In addition, Sierra Leone also had a range of more traditional associational groups, some of which still exist and enjoy large followings: the secret societies (male - the
Poro, the Wonde, Gbangbani, Hunting and Ojeh; and female - Bondo); youth, women’s and farmers’ associations, football, dance, and social clubs, cooperative societies and financial clubs (Vincent 2013, p. 32).
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The limited literature on modern civil society organisations in Sierra Leone is at pains to stress that a great number of different types of civil society groups continues to exist. The 2014 Civicus report identifies four distinct types “based on who their members are and what broad types of public ends they pursue” (2014, p 16-17):
a. Social clubs/mutual benefit organisations [including traditional societies] b. Elite professional associations c. Good governance and rights-promoting organisations d. Service delivery and development not-for-profit organisations
Each of these groups has its own history: The traditional societies are the oldest out of all forms of associational life; to this day they count the majority of Sierra Leoneans as their members. The elite professional associations have been around since the late 19th century (Wyse 2003, p. 22). Good governance and rights promoting are a more recent phenomenon and seem to have a more chequered history. A 2007 Campaign for Good
Governance and Civicus report recounts:
From independence to 1990, the public space necessary for civil society to develop was not only lacking, but also far more restricted. There was a tendency for civil society to accept the line of present government, sometimes even working in their favour. Certain civil society movements were even created by political regimes, and thus lacked autonomy, credibility, and neutrality. This manifested an irony of the situation characterised by the fact that these civil society groups were aware of the need to hold public officials accountable, but chose not to do so, because of their individual selfish interests. One, could therefore, observe that at a certain period in the socio-economic and political development of Sierra Leone, civil society movements did not contribute to democracy.
(Campaign for Good Governance and Civicus 2007, p. 20)
In 2014 the Campaign for Good Governance and Civicus published a follow-up report that charts the emergence of a new wave of human rights promoting civil society organisations, many of which became active during the civil war (Campaign for Good
Governance and Civicus 2014, p. 15). In addition to the human rights’ focused
128 organisations that emerged post-war, a fourth group of civil society actors emerged around the same time. Those who have written extensively about Sierra Leone civil society sometimes call this group ‘service delivery organisations’, ‘development not- for-profit organisations’ and sometimes ‘formal civil society groups’. They are a relatively new phenomenon in Sierra Leone. When, in 2009, the Government of Sierra
Leone demanded that CSOs officially register, it found that of the 300 officially registered organisations nearly two-thirds had been founded between 1998 and 2006
(Kanyako 2011, pp. 4-5).
Many of the entities that fall into the fourth category (I will call them ‘formal civil society organisation’) have a bad reputation in Sierra Leone. Various reports depict these organisations as often controlled by one man or a small group of people and existing primarily as a vehicle for accessing foreign aid. While this is not a fair depiction of the entire ‘formal CSO’ sector, the prevalence of untrustworthy CSOs appears to be such a feature of organisational life in Sierra Leone that the international advocacy group for civil society organisations CIVICUS warns repeatedly that accountability within Sierra Leonean CSOs’ organisational structure is often lacking.
Its 2007 Civil Society Index Report for Sierra Leone noted:
The CSI [civil society index] assessment reveals that civil society values are poor in Sierra Leone. CSOs do not practice good governance and gender equity. CSOs are characterised by a culture of secrecy and corruption. Widespread corruption has been reported within CSOs. Most CSOs lack internal democracy, accountability and transparency, and their leadership, for most, is in the hands of their respective founders. Sometimes the CSO is even set up as a family organisation aimed at attracting donor funding. (Campaign for Good Governance and CIVICUS 2007, p. 8)
According to the authors of the 2014 Civil Society Index - Rapid Assessment report, the situation, seven years later, had not improved significantly:
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In the opinions of a number of key informants, weaknesses persist in CSOs’ internal governance partly as a matter of choice by CSO leaders, particularly on the part of non-membership organisations, given that they do not have to be accountable to their members over the way they function and use their funding. The suggestion is that many heads of CSOs benefit materially from internal governance weaknesses in their organisations. (Campaign for Good Governance and CIVICUS 2014, p. 21)
In a report for the World Bank, Sesay et al sum up a number of the reasons why this type of CSO is common in Sierra Leone. Firstly, they argue, their emergence in the immediate aftermath of the conflict is a symptom of that time and situation: “[…] there are many more unaccountable and fraudulent CSOs in zones of post-conflict recovery than in any other circumstance. The mushrooming of such organisations is a logical response to the vacuum created by the lack of public funds and services for the people, and the immediate influx of donor funding” (2007, p. 1). In a report on strengthening civil society in fragile states, de Weijer and Kilnes agree on this point (2012, pp. 5-6).
Sesay et al further argue: “The urgency of humanitarian support provides a perfect opportunity for the unemployed or unpaid civil servants in chaotic political conditions and dubious commitment to the communities, to form organizations” while “[…] the absence of sanctioned legal frameworks in the fragile states hampers serious intentions to implement necessary checks and balances or accountability mechanisms”. Even when CSOs manage to do a good job, Sesay et al warn, the sector runs the risk of being tarnished by developing country governments whose officials may consider donor funded CSOs their competitors and indict CSOs for being inefficient, or loyal to foreign agendas (2007, p. 1).
In addition to some CSOs’ lack of integrity, many such organisations lack of capacity to implement development programmes makes it even harder to trust them with donor funds. All of the above-mentioned civil society-focused reports highlight a general
130 lack of capacity as common in CSOs in Sierra Leone, as well as a lack of merit-based recruitment and an absence of a clear mandate. The reports caution that as long as civil society organisations in Sierra Leone do not receive support to improve their internal structures, as long as they are not are assisted to rationalise the number of duplicitous
CSO networks and become better regulated in terms of minimum standards of financial management as a precondition to CSO registration, the sector will be unable to fulfil its much needed role of holding government to account (Campaign for Good
Governance and CIVICUS 2007, 2014, Sesay et al 2007).
4.5 The Free Healthcare Initiative
Before exploring a series of case studies focused on accountability in Sierra Leone’s primary healthcare sector (in chapters five to eight) it is important to first review Sierra
Leone’s health system. By examining its recent history it is possible to arrive at a greater understanding of its ongoing challenges.
As the short section on the post-war years indicated (4.2.6), a lot more basic service improvements could have been achieved during Sierra Leone’s ‘post-war reconstruction years’ if resources had not been squandered by corrupt politicians and their cronies. In the health sector in particular, the challenges were huge: in 2002, only
30% per cent of health facilities were functional, and staff shortages were acute (World
Bank 2003, p. i).
The 2007 Human Development Report for Sierra Leone provides evidence of the country’s failure to improve its citizen’s lives. It placed Sierra Leone 176th out of 177 countries listed, citing “low life expectancy (39% probability at birth of not surviving 131 to age 40), high illiteracy (61%, among the highest in the world), and a high 70% of the population below the national poverty line” (UNDP 2007, pp. xii-xiii). The same report suggests: “Coverage of health centres and clinics has expanded since 2005, but many are of poor quality, inaccessible, with inadequate personnel and medicines. Only
Western Area [the capital Freetown and immediate surrounds] meets WHO staffing ratios of one doctor per 12,000 population; Kailahun district has one per 191,340”
(2007, p. xiii). Amnesty International described the situation as follows:
The Sierra Leone health care system suffers from a lack of trained and sufficiently motivated staff, insufficient drugs and medical supplies, grossly inadequate provision of emergency obstetric care for complications, poor infrastructure, and an ineffective referral system. There is little or no accountability at the local or national level to ensure that the health care system functions effectively.
(Amnesty International 2009, p. 2)
Bertone et al note that “[…] between 2002 and 2009 the progress towards policy- making for a coherent restructuring of the health workforce was not rapid or effective.
Although the challenges were correctly identified by the MoHS and potential solutions being proposed […] very little was happening in practice” (Bertone et al 2014, p. 4).
The Ministry of Health and Sanitation admitted itself in the 2012 Human Resources for Health policy (2012) that: “there have been two attempts to formulate national policy to guide the development and management of human resource for health in
Sierra Leone […], but none were finalised or adopted for implementation” (MoHS
2012, p.6).
A 2006 study showed that despite 70% of the population living below the poverty line, two-thirds of all spending on health in Sierra Leone was private out-of-pocket spending, and households reported cost as a major barrier to access, (Medecins Sans
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Frontieres32 cited in World Bank 2010, p. 132). The article by Bertone et al, providing an overview of Human Resources for Health policies in Sierra Leone, notes that in the
2004-2007 period “the consequence of a lack of political guidance and strategic vision was a general sense of ‘purposelessness’” (2014, p. 5). It adds:
Obviously, the broader political dimension is important to understand the lack of strategic vision for the health sector. The government elected in 2002, which seemed to initially enjoy some support, soon lost much of its popularity given its weaknesses in terms of leadership to drive for reform, especially compared to the following administration in power from 2007. (Bertone et al 2014, p. 5)
Little changed in Sierra Leone’s health sector until everything changed with the introduction of the Free Healthcare Initiative in 2010. At that point, the health sector was at breaking point, and the system, especially in rural areas, was to a large extent
‘informal’. A 2009 Amnesty International report found that in Koinadugu District, 48 per cent of the maternal and child health aides and community health officers had not
been paid since the end of 2008. The report highlighted that the healthcare staff survived by charging for their services and for drugs, some of which were supposed to be free for patients (2009, p. 17). The authors furthermore noted: “[…] in most areas where Amnesty International carried out research, anyone working in the clinic, whether paid or unpaid, would unilaterally and illegally charge fees and keep the money” (2009, p. 29).
The change of government in 2007 heightened expectations that some of Sierra
Leone’s dismal development indicators would finally shift (International Crisis Group
2008). The years following APC’s 2007 election win coincided with an international donor trend focusing on the results of aid spending (Barder 2012a, Barder 2012b,
Klingebiel 2011). While the debate around the usefulness of results-focused
32 The original study was written by: Latreille, Coppens, Philips, van Herp, Bachy, & Ponsar, 2006. 133 international development continues, it is likely to have been a trend that led the international community to assess its relationship with the Government of Sierra
Leone (OECD 2010), as the country remained consistently among the bottom five nations with the world’s highest maternal, infant and child mortality (UNDP 2014,
UNICEF 2014). Ambitious targets set out in the Millennium Development Goals
(MDGs) added pressure on UN agencies in poorly performing countries in particular.
In a 2009 report, reflecting on progress to achieve the MDGs, UN Secretary-General
Ban Ki-moon warned: "We have made important progress […] but we have been moving too slowly to meet our goals" (UN 2009).
In 2009, President Koroma presided over the opening of the Bumbuna hydroelectric dam, providing Freetown with its first ever reliable power source. Scharff believes that the dam’s completion emboldened the President to start looking towards his next big goal, perhaps realising along the way that this next project needed to bring a development dividend to the whole country, if APC were to have any chance of winning the next election (2012, pp. 2-3). That next big goal became the ‘free healthcare initiative for pregnant women and children under five’.
4.5.1 The overhaul of the health system
Detailed descriptions have been written about the process that led to the introduction of the Free Healthcare Initiative (FHCI), which was launched on April 27, 2010 (Chu
2012, Donnelly 2011, Scharff 2012). All recount the unprecedented collaboration that led to the overhaul of the primary healthcare system. Personal involvement of
President Koroma at every step seems to have pushed and sustained the momentum.
The implementation schedule was tight: from the first meeting in August 2009 to the
134 launch of the FHCI in April 2010. “We had to do in six months’ time what normal policy processes would take five years to do” Mr Mdoe, the head of UNICEF explained (Scharff 2012, p. 15).
The initial assessments exposed a staggering lack of facilities: six out of the thirteen districts could not provide emergency obstetric care. Throughout Sierra Leone, there was just one doctor available per 33,000 people33 and most doctors were found in the capital or other urban centres. Throughout the country, renovations and the construction of new health centres were needed; many were to be finished off just days before the launch of the initiative (Chu 2012, Donnelly 2011).
The most significant challenge was related to human resources; the health worker payroll included a lot of ghost workers, individuals who never came to work because they chose not to, had retired, left the country or had died, but whose salaries were still being collected by relatives. An extensive cross-check of the payroll was carried out and approximately 1,000 individuals were struck off the payroll. Once the ghost workers were eliminated, new staff could be hired: accounts of how many were hired vary significantly, ranging from 1,000 (Donnelly 2012), to 2,000 (MoHS 2011), to
3,000 (Scharff 2012), and several authors suggest that many of the ghost workers were not struck off the list, but simply returned to work for the first time in years when they realise their salary would otherwise stop being paid (Chu 2012, p. 2, Scharff 2012, p.
10).
Along with updating the payroll, the salary scale had to be adjusted. The most basic nurses’ salary was raised from less than 100 US$ to around 200US$ per month, while some doctor’s pay went from 250US$ monthly, to 1000 US$, depending on the grade.
33 The World Health Organisation recommends a minimum of 1 per 12,000 in developing countries 135
The new hires, re-grading of staff and the increased wages meant that the health sector wage bill jumped from US$ 6 million to US$ 18 million annually (Donnelly 2011, p.
1394, Scharff 2012, p. 13, Stevenson et al 2012).
4.5.2 The weaknesses that affected the implementation of the Free Healthcare Initiative
While the Free Healthcare Initiative’s first months were noted for the massive increase in patients’ attendance, it soon became clear that the bonanza of free medicine led to unforeseen misuse. Consignments of drugs destined for free healthcare patients were sold off by health workers, medical supply deliverers and warehouse store keepers, and they turned up at private pharmacies, with drug peddlers (commonly known as ‘pepper doctors’) and in clinics in neighbouring Liberia and Guinea. Within months of the launch Sierra Leone’s newspapers, government and donor investigations were filled with reports of fraud. Eye witnesses attested that pregnant women and young children were still being charged for services and medicine that should have been free
(Amnesty International 2011, Bhandari 2011, IRIN 2012, Sierra Express Media 2011).
Sierra Leone’s Anti-Corruption Commission got involved when it became clear that the theft of drugs was such, that it was having a serious impact on the supply chain of medicine throughout the country. The scandal was fast becoming an embarrassment for the government, the donor community and the implementing agencies (Sierra
Express Media 2013). In one instance, UNICEF, as coordinators of the medical supplies distribution on behalf all FHCI donors, agreed to refund Irish Aid for the leakage of up to 60% of nutrition supplements the Irish Government had funded. The nutrition supplement sachets were provided as part of the package of free medicine 136 available to malnourished children under five. The 2011 annual report of the Irish
Audit Committee of the Department of Foreign Affairs and Trade noted:
An investigation undertaken by UNICEF found that there were weaknesses across the entire supply chain management system with particular emphasis on poor record keeping of supplies flow. The report indicated that at least 27% of the therapeutic food supplied could not be accounted for in the records system examined during the audit and further stated that, due to lack of proper records, up to 60% of stocks could have been misappropriated or ‘leaked’. (Government of Ireland 2012, p. 12-13)
In August 2011, Amnesty International issued a damning report34 providing evidence
(from a large sample of women and healthcare workers) of the free healthcare initiative’s shortcomings:
Women and girls report two significant problems with the FHCI: either drugs and other essential medical supplies are simply not available at the health facilities, or they are charged for medicines and care that are supposed to be provided for free. Often, essential drugs for women in pregnancy and childbirth are not available for free, they are available at a price – in the same facility – as ‘cost recovery’ drugs.
(Amnesty International 2011, p. 14)
The changes to the health system had been implemented fast but without any regard for ‘change management’. Sierra Leone’s clinics went overnight from a system where multiple unpaid employees worked in health facilities and were able to charge what they liked to make up for their lack of salary, to a system where only one or two designated healthcare staff were on payroll, and officially, the rest of the staff was now unable to charge the majority of the clinic users for the health services they provided.
In addition, the drive to stop traditional birth attendants (TBAs) from practicing in the communities drove the more active TBAs into the clinics as volunteers (often being put to work to assist with ante-natal care and the delivery of babies, as health workers
34 The report was a follow up from their 2009 report that provided evidence of the prohibitive cost of maternal care, which led to numerous women’s deaths during child birth: Amnesty International (2009) Out of reach. The cost of maternal health in Sierra Leone, London: Amnesty International. 137 had little experience in doing so). The increased presence of TBAs in clinics may have helped to encourage rural women to give birth at health facilities rather than at home, it has also brought about its own problems: how do clinics pay TBAs for their assistance?
Health facilities were not entirely without funds to ‘incentivise’ the work of volunteers, although the system was far from ideal. The Performance Based Finance (PBF) facility was introduced less than a year after the free healthcare. The World Bank funded cash incentive scheme provided a mix of salary top-up for health workers and funds to cover volunteers’ stipends, incidental expenditures for repairs and other clinic running cost. The finance facility was introduced as a salary top-up system that rewarded health workers for the heavier work load they faced since the free healthcare and it incentivised greater efforts to reach patients or encourage their regular attendance, by linking bonuses to numbers of ante-natal visits, facility deliveries, full vaccinations for babies under the age of one, etc.
The idea of linking (bonus) pay to performance was generally conceived as a good way of promoting greater health worker efficacy, and the introduction of such a programme was in line with recent trends in human resources for health thinking
(Ireland et al 2011, Meessen et al 2011). Whether such schemes are successful depends on their design and also on the political will to implement them well. Sierra
Leone’s PBF intervention has experienced challenges on both counts (Bertone et al
2014).
The nationwide PBF salary top-ups provided a significant salary boost for health workers who were already receiving an income (albeit a low one) to compensate for the heavier workload due to the free healthcare. Health workers- in-charge received the 138
PBF payments into their bank accounts and were responsible for dividing the quarterly payments among clinics’ staff and volunteers. This has brought with it the inevitable potential of conflict over how much was received by the health worker in charge and how much was paid out to the rest of the team. The quarterly payments are supposed to be split into two: 60% for the staff and 40% for clinic maintenance, travel expenses and other essential costs.
The PBF system replaced a flat rate maintenance grant to health facilities which was theoretically in place before the introduction of the FCHI, but was not regularly paid out. According to the PBF guidelines, the programme […] works complementary to
Free Healthcare, and offers to health facilities a compensation for the loss of income through patient fees (Cordaid 2014, p 10). The PBS system has now been in place throughout the country since early 2012, but the system’s implementation problems meant that there were huge delays in pay-outs to health workers, which hampered some of the positive impact the payment supplement could have had. An external evaluation of the PBS programme, carried out by the NGO Cordaid in 2013-2014 concluded that “[…] due to long delays in payments, the lack of transparency in how amounts were reached, health workers at grass root level completely missed the
‘emotion’ of payment for performance” (2014, p 72).
As with so many aspect of a national health system, the devil is often in the detail, and that is certainly the case with Sierra Leone’s PBF system. There appear to be no openly accessible documents that provide the guidelines related to the spending of PBF funds. Interviews with health workers, TBAs and clinic-based volunteers, which were conducted for the case studies presented in this thesis, showed that in most cases the
‘in-charge’ paid TBAs, vaccinators and cleaners 2% of the PBF payment (or of the 139
40% or the 60% share of the total, depending on who you ask). The commonly held view that it should be 2% appeared to have been based on guidance from district health authorities nationwide. In the cases where a health worker revealed the value of the last received PBF funds, it did not take long to work out that this resulted in payments for informal workers amounting to anything between 10 US$ and 50 US$ per quarter; hardly a living wage. Although the PBF policy documents stated that the 40% of the total amount for each clinic was intended to replace the funds that were otherwise received from fee-paying patients (pre-free healthcare), it is clear that nobody factored in the amounts that patients paid directly to informal healthcare staff. If a health system remains heavily reliant on such staff, as it does, it is important that sufficient funds are made available to ensure that clinics can pay them(or better still, if such funds were used for the salaries of more health workers who are on the payroll). While many health workers in charge were keen to reassure me that staff who were not on payroll were compensated with PBF funds, few revealed that the PBF share for informal staff was hardly sufficient compensation. The terms of reference for Cordaid’s review did not include any investigation into the spending of the of PBF, other than to check in what way clinics went about spending the capital grant portion of the PBF funds. They concluded that:
Of all PHUs 62% made action plans, at least a plan how to utilise the money paid from the PBF programme. Sometimes PHUs just produced procurement lists. Often those plans were made shortly before money was withdrawn from the bank accounts.
(Cordaid 2014, p. 60)
With regards to the PBF programme’s objective to “Increase the equity of distribution of resources with funds from PBF allowing facilities to hire contractual workers and finance outreach activities”, the report adds:
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Equity of distribution of funds may have taken place using district-based payment formula, but was not visible for grass root workers. The flow of funds in general was not regular enough to hire contract workers (with exception of the two PBF hospitals).
(Cordaid 2014, p. 73)
The field research suggests that there appeared to be a direct correlation between the design of Sierra Leone’s primary healthcare system - with a continued health workers shortages, but significant bonuses for those on payroll - and the routine charging for
‘free’ healthcare to top up the small PBF allocation for the clinic ‘volunteers’. This systemic charging remains the largest barrier to the improvement of accountability in the sector.
4.5.3 CSO’s role in supporting the delivery of free healthcare – sensitisation and monitoring
Despite the fact that Sierra Leonean and international NGOs had actively supported the president’s plan to introduce free healthcare and were at the table during the planning and negotiating stages (Donnelly 2010, p. 1395), civil society was not given an official role to support the implementation of the FHCI. While many documents produced in the run-up and after the introduction of the FHCI mention the importance of communicating the entitlements that the FHCI will provide, there is no evidence that the stakeholders (the government of Sierra Leone, donor, NGOs and CSOs) agreed on a country-wide strategy to ensure that people in every district received sufficient information about the FHCI. Instead, it seems as if NGOs and donors all decided for themselves what sort of information campaigns they could carry out. Their documentation shows that a wide variety of FHCI sensitisation activities were carried
141 out, from radio programmes to school club debates or the training of health workers and TBAs (e.g. ActionAid and Marie Stopes 2010, UNFPA 2013). There is no data available as to which district received most FHCI information campaigns, but it can be assumed that without coordination, certain areas must have been targeted by several sensitisation initiatives while other, more remote locations, may have barely received any. A slightly more systematic approach to engaging civil society in the sensitisation and monitoring of the free healthcare did not start until much later.
From 2011 onwards, the word ‘accountability’ became increasingly common in the language around the delivery of free healthcare. During a meeting with health workers in Makeni, one of Sierra Leone’s main towns, an Anti-Corruption Commission official stated, in relation to the FHCI: “We stand the risk of losing the gains we have made in improving the lives of people if we fail to enhance transparency and accountability"
(Concord Times 2012). The aforementioned Amnesty International report states: “A critical shortcoming within the healthcare system is the absence of any effective monitoring and accountability systems, without which reforms cannot succeed” (2011, p. 4). In August 2012, the Ministry of Health and Sanitation and the donor community tightened the monitoring of the drug distribution system in response to the many cases of alleged fraud. Despite the improved oversight of the drug supply chain, it soon became clear that monitoring was needed at many more entry points.
By 2012, almost two years after the introduction of the FHCI, the advocacy network
Health for All Coalition (HFAC), which had been the most prominent agency advocating for free healthcare, was given a donor funded government contract for the nationwide monitoring of the delivery of free healthcare (Concord Times 2012, Health for All Coalition 2010). HFAC was contracted to set up a Facility Management
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Committee (FMC) in every location with a health facility throughout Sierra. In addition, HFAC was in receipt of a grant to carry out a nationwide monitoring of the free healthcare. The agency recruited a district-based monitoring coordinators for each of Sierra Leone’s thirteen districts and these monitors, in turn, recruited ‘monitoring volunteers’ covering every community throughout the country.
For this research I interviewed the HFAC district coordinators in Tonkolili, Kono and
Kailahun (KI21, KI74, KI108) in order to establish how the HFAC intervention might impact on the research I conducted for this thesis. It soon became apparent that the
HFAC programme was highly ineffective. The monitoring ‘volunteers’ were being paid so little that many did not bother visiting clinics. Many HFAC district coordinators were not provided with sufficient funds to have their own office space, and one of them complained about having to use his personal laptop to carry out his job. HFAC’s failure to carry out its monitoring duty was most evident in the lack of activity among the FMCs, which, one would have assumed, would not have been dormant if they had been visited regularly by a HFAC monitoring volunteer, especially given the fact that the FMCs were established by the same organisation.
Health for All Coalition was allegedly tasked by the Ministry of Health and Sanitation with setting up FMCs with little or no consultation with the district health authorities
(Grandvoinnet et al 2015). The establishment of the monitoring groups was completed using a basic formula: each FMC should be led by a chairlady, the group should be comprised of three women and two men in total, and one FMC member should be able to read and write. One day’s worth of training was offered to the chairlady, who was supposed to pass on the knowledge to her fellow committee members (KI74). Little attention was paid to the many already established health committees, which had often
143 been nurtured by NGOs that had rebuilt clinics after the war, and had worked hard to establish community engagement. The fact that the setting up of the FMCs came several months before Sierra Leone’s 2012 elections and involved the handing out of a mobile phone to the chairlady of each FMC, was perceived by many as electioneering rather than a concerted effort to improve health workers’ accountability (Grandvoinnet et al 2015, p. 236).
The field research shows that the free phones soon disappeared, broke or were used for every-day life rather than in health monitoring service. Some FMC chairladies drifted away and many stopped calling meetings. The FMCs were generally still called upon to verify the delivery of free healthcare medicines at the clinic, but in many cases that was the only activity that was still performed by FMCs.
The monitoring by HFAC was the first and only attempt to engage a civil society organisation in the implementation of the FHCI. By the time HFAC commenced its engagement, many national and international non-governmental organisations had already started to respond to the demand for improved accountability in the health sector by conducting health monitoring projects – again, in an uncoordinated manner.
Several new CSOs sprung up dedicated to health and accountability issues, while other
CSOs with a more general mandate also started to receive contacts for the ‘monitoring of the free healthcare’. For the most part, these agencies conducted surveys and announced that the records held in the clinics did not tally with the medicine in stock on the clinic’s shelves, nor with the inventory of lists held for each clinic at district level (see, for example, Health for All Coalition 2011, SEND Foundation 2012).
Often, these organisations focused on national-level advocacy; such as collecting data about the failures of the free healthcare initiative and using it to launch a report and get
144 newspaper coverage at national-level (e.g. Sierra Express Media, Sept 5, 2011), without attempting to change the situation on the ground. The majority of organisations monitored clinics without any coordination between one another or with the de-facto national monitor, Health for All Coalition, which, by the end of 2012, had lost some of its donor support, due to a lack of data analysis and reporting capacity
(Stevenson et al 2012, p. 37).
The challenges encountered with the introduction of the free healthcare initiative created an opportunity for Sierra Leone’s civil society to become involved in mobilising the citizen voice to demand greater accountability. As this section showed, the government and the donor community which had so actively and positively collaborated to prepare for the launch of the FHCI (Chu 2012, Donnelly 2011), missed an opportunity to create a coordination mechanism. This would have helped to ensure that NGO and CSO avoided duplication and had a forum in which challenges and lessons learnt could have been discussed. Given the corruption and lack of capacity problems within Sierra Leone, which were highlighted in section 4.4, it is unclear whether there would have been much appetite for such coordination, however, better coordination would have been able to ensure better coverage of FHCI sensitisation efforts.
4.6 Conclusion
Chapter four aimed to describe the specific context in Sierra Leone in which the four case study interventions were implemented. As the brief history outlined, from the colonial days to the onset of the civil war, Sierra Leone cannot point to many periods
145 in which its governance was ever focused on the interest and wellbeing of the people rather than of the ruling elite (perhaps with the exception of the three-year post- colonial period when the country was ruled by Milton Margai 1961-1964). It is clear from the history that the habit of self-enrichment and nepotism of those in power became a recurring problem that has undermined the development of Sierra Leone as a whole.
Section 4.3 has shown how the ongoing efforts to bring local governance and basic public service provision to every corner of Sierra Leone were undermined by political interference. The enshrining into law of the powers of the traditional chiefdom authorities and the lack of clarity about their authority in terms of raising local taxes, has clearly hampered the successful institutionalisation of the local council system.
Continued delays in some of the crucial steps of the government’s decentralisation plans, such as fiscal decentralisation and human resource management, further contribute to the continued weakness of the local authorities. These issues have a significant impact on district government’s ability to support and oversee the delivery of basic healthcare provision. Section 4.4, focused on CSOs in Sierra Leone, presented evidence of common challenges encountered in this sector. While many types of civil society organisations in Sierra Leone provide invaluable local support to its members or its local communities, there is a sub-group of civil society organisations that greatly lacks internal accountability. It is often these organisations that vie for contracts with international NGOs, and in the next chapters it will be clear that even reputable international NGOs sometimes contract CSOs which turn out to be not entirely accountable. Section 4.5 described the history and context under which Sierra Leone’s current flagship Free Healthcare Initiative (FHCI) was established. It too has been marred by challenges, many of which have their roots in the chaotic nature of Sierra 146
Leone’s pre-FHCI health system. It is important to note that the country introduced the
FHCI almost overnight, with little ‘change management’ on the ground. While many of the bold policy decision, such as the health workers’ wage rises, were designed to pre-empt serious accountability problems from occurring, it is evident that it was simply impossible to switch from a wholly dysfunctional and informal system to a system whereby health workers pass on free medicines and provide treatment without ever being tempted to charge for them.
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148
Chapter 5 - Case Study A: Community Monitoring
with Score Cards
5.1 Introduction
This chapter presents the first of the four cases on which the empirical research focuses. All four cases are examples of ‘social accountability interventions in the health sector in Sierra Leone’. As explained in earlier chapters, two of the cases were undertaken in Tonkolili District, while the other two cases were based on projects carried out in Kono and Kailahun Districts. This chapter starts at 5.2 with an examination of Tonkolili District, the environment in which this case was set. Section
5.3 gives details about the specific accountability methodology, Community
Monitoring with Score Card (CM), which is examined in this chapter. Section 5.4 presents the findings from the interviews, case studies and other sources, while section
5.5 uses the analytical framework to examine the methodology and the outcome of the
CM intervention. Section 5.6 concludes.
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5.2 Tonkolili District
The case study described in this
chapter is based on the implementation
of a community monitoring with
scorecards intervention in Tonkolili
District.
Most striking about Tonkolili District
is its conspicuous absence from being
mentioned in the literature on Sierra
Leone’s civil war. Foday Sankoh, the enigmatic leader of the rebel Revolutionary
United Front (RUF) hailed from Kholifa Rowalla chiefdom in Tonkolili and for much of the war, Tonkolili District was a stronghold of the RUF. There is evidence that a number of RUF training camps for new recruits were located in Tonkolili and Bombali
Districts (Netherlands, Ministerie van Buitenlandse Zaken 2004). There is barely a mention of the area’s central role, despite the fact that some of the most active fighting in the latter stages of the civil war took place in Tonkolili District, causing terrible damage to the district’s infrastructure. Archibald and Richards state that: “When the
RUF regrouped in the north from 1996, based in a major forest camp in the Kangari hills, and later (1997-98) in Makeni and Magburaka, the main towns in Bombali and
Tonkolili Districts, Temne villagers were displaced southwards into Kpa Mende territory” (2002, p. 342). Richards is the only author who mentions the district in some detail. In an illustration of the unorthodox alliances that were forged during the civil war, he describes:
With some military advice from Executive Outcomes, Bai Sunthaba succeeded to drive the RUF northwards. The frontline then became fixed in Tane Chiefdom [Tonkolili District], where the main motor road ascends the Kangari Hills scarp on its 150
way from Makeni to Kono. North of this line the villages are today physically undamaged, because this is an area the RUF controlled. South of the line most villages were levelled in the course of attacks and counter attacks between the RUF and CDF (1998-99). (Richards 2003, p. 29)
The reports of post-war reconstruction catalogue the destruction and destitution inflicted on Tonkolili District during the war. A World Bank education report describes how in 2002, over 70% of all the schools in Tonkolili were destroyed and in need of serious restoration or rebuilding (Wang 2007, p. 69).
Present day Tonkolili is a hub of mining activities, predominantly targeting its reserves of iron ore, bauxite and gold (Mihalyi 2015). Tonkolili allegedly has the third largest iron ore deposit in the world. The majority of the extractives now mined in Tonkolili were not discovered until after the civil war. Former mercenaries and other shareholders with a chequered past have been among the most prominent investors in
Tonkolili’s mines. A lack of transparency characterised the purchase and resale of mining concessions in the immediate post-war period as much as it did pre-war (Pech
1999, Reuters 2012). High international demand for minerals gave Sierra Leone a brief spell in the limelight in 2013, when the IMF predicted that Sierra Leone was on course to experience a growth rate “[…] projected to average 13.7 percent in 2013–14” (2013, p. 8), which would have been the largest economic growth an African country would have ever achieved. Sierra Leone’s growth rates never reached these heights, but in this brief period, mining companies invested significantly in infrastructure. African
Minerals, until recently the largest iron ore mining company operational in Sierra
Leone, completed the extension of its private railway from the port of Pepel to its iron ore mine in Tonkolili in 2012, the year large scale production started (Mihalyi 2015).
151
Despite the millions invested, benefits to the population of Tonkolili have been limited to low paid manual jobs in the mining industry, while mining companies have taken control of vast swathes of countryside and demanded the relocation of communities that live on top of precious reserves. Mining companies in Tonkolili have been criticised for not providing the people they resettled with commensurable farmland, schools and health centres (Human Rights Watch 2014).
Present day Tonkolili’s health and poverty status provides evidence of the lack of economic dividend that its population derives from the resources in the ground:
Tonkolili is Sierra Leone’s poorest district, with more than three quarters of its population living below the poverty line.35 A similar percentage of the population experience regular food insecurity, with over 32% experiencing chronic malnutrition resulting in stunting. The under-five mortality rate is 133 per 1,000 live births and life expectancy at birth is just under 48 years. Only 60 percent of all primary school-aged children are currently enrolled in formal education (UNOCHA 2015).
The recent, controversial receivership and subsequent sale of African Minerals’
Tonkolili iron ore operations to the Chinese company Shandong Iron and Steel Group, has led to a cessation of all its mining activities and the loss of over 8,000 local jobs
(Reuters 2015). It once again emphasises that the chances of ordinary Sierra Leoneans benefiting from the country’s mineral riches are uncertain at best.
35 Calculations based on SLIHS (2011) World Bank and Statistics Sierra Leone. 152
5.3 Case Study A: Community Monitoring
The field research during which data was collected for all four case studies followed the same pattern at each location: I travelled to the health centres that had been selected for the research because they were the focus of one of the four social accountability interventions under study, and I did the following:
I conducted a one-to-one interview with the health worker in charge.
If the Facility Management Committee (FMC)36 was central to the intervention, I interviewed one or more members of the FMC.
If time allowed (for instance, if there was no FMC to interview) I also interviewed a traditional birth attendant or another volunteer who worked at the clinic.
I then travelled to a nearby village, or to the edge of the village where the health centre was, and I conducted a focus group discussion with 6-8 women who were regular users of the nearby health centre (predominantly pregnant women and mothers with children under five years of age).
5.3.1 The Community Monitoring intervention
The Community Monitoring with Score Cards (CM) intervention shall be discussed first, as it is one of the most commonly used social accountability methodologies. The rationale for the use of this method is described as follows:
Recent experiments have highlighted the power of non-financial incentives to improve the performance of individuals performing public service. Such mechanisms utilize the power of social sanctions and rewards, through mechanisms such as public recognition
36 As noted in chapter four, a Facility Management Committee is a village-based citizen group tasked with overseeing and supporting their local health facility. In 2012, a FMC was established in the nearest community to every local health facility in Sierra Leone, but many are no longer actively engaged in the local clinic. 153
and community monitoring, and are attractive for three reasons: First, they are cost- effective […]; Second, non-financial awards avoid the potential crowding-out effect that performance based payment schemes can have on intrinsic motivation […]. Finally, non-financial incentives also obviate the significant monitoring and other administrative costs that are incurred by performance-based incentive schemes, and can operate even in the presence of limited liability and moral hazard.
(IPA et al 2015, p. 6)
The basic premise of ‘community monitoring in a public service provision context’ is the idea that communities and service providers can work together to improve service delivery and uptake if both parties jointly analyse problems, bottlenecks and unhelpful behaviours, and agree on a joint action plan to remedy any problems that exist.
In practice it means that (usually) an external agency facilitates both parties to meet and evaluate the service they provide or receive, using a set of indicators (in the case of the intervention I studied in Tonkolili, scorecards were used). The service users and health workers then draw up a joint ‘compact’ or agreement, in which both parties commit to changing their behaviour in order to improve service outcomes. The community is often invited to monitor the compact, and a series of evaluation meetings are held to check on the progress and continued commitment from both parties. If all goes well frontline service providers are expected to improve their effort and to work in a more accountable manner, while service users are encouraged to improve their health, education (or other service) seeking behaviour. This can, for example, include requiring parents to ensure that children attend school all year round, parents committing to fully vaccinate their children, or seeking care for illnesses in a timely manner. The first meeting, during which the compact is drawn up, is always the most important. Prior to this, according to most community monitoring guidance notes, the community is usually provided with information (by a facilitating NGO), which should allow the community to make some objective judgments on whether the services they
154 receive meet basic standards set by government or about the relative quality of the basic services they receive.
Before the implementation is discussed, the following points need to be clarified: The
Community Monitoring and the Non-Financial Award interventions I examined were part of a randomised control trial (RCT), designed and funded by the World Bank and implemented by three international NGOs which in turn subcontracted the field work
Figure 5: Diagram of entities involved in Community Monitoring out to local civil society and Non-financial awards RCT organisation (CSOs) in
the implementation
areas (see figure 5).
Data for the RCT was
collected by a
specialised RCT data
collecting entity called
Innovations for Poverty
Action (IPA), based in New Haven, Connecticut.
To ensure that I created data that was comparable to the other case studies, I treated these two interventions in exactly the same way as the Participatory Monitoring and
Evaluation and the Mixed Methods interventions that were implemented by Christian
Aid partner agencies (discussed in chapters seven and eight).
The RCT had a strong quantitative data component, but I had no access to any of the data that was collected by IPA. I obtained various reports and articles about this RCT that were written by the World Bank and IPA a year after my field research was completed. I use them in this thesis just as I used the field reports generated by 155
Christian Aid’s partner agencies. As I pointed out in chapter three, World Bank staff attended one of the feedback sessions I organised in Freetown at the end of my field visit. While they were interested in my findings, the RCT was largely focused on their own quantitative data collection and therefore none of my data was used in the drafting of their reports. The entire RCT targeted a total of two hundred and fifty-four health clinics in four districts of Sierra Leone: Bo, Bombali, Kenema and Tonkolili (IPA et al
2015, p. 9).
The specific part of the RCT intervention that I focused on was the work of Concern
Worldwide, one of the three participating organisations (illustrated as the red outlined boxes in figure 5). Concern has a long history of working in Tonkolili District. To implement the World Bank trail, Concern subcontracted the Tonkolili-based field work out to four local CSOs: Pikin-to-Pikin, COBTRIP, OPARD and CIDA. These four agencies simultaneously implemented the Community Monitoring and the Non-
Financial Awards method (written up in chapter six). The four agencies jointly targeted twenty-five clinics in which the Community Monitoring method was implemented, and another twenty-five where the Non-Financial Awards method was used.
The World Bank provided the three international NGOs instructions as to how the community monitoring interventions should take place in each community. These were based on a successful community monitoring pilot study conducted by the World Bank in Uganda (Björkman and Svensson 2007)37. Each of the three INGOs received strict implementation guidelines in order to minimise variance across the three agencies (and their subcontracting CSOs). Concern’s subcontracting CSOs were responsible for
37 This was confirmed in person by one of the contributors to the RCT research design, Nicolas Menzies from the World Bank, who was present at a feedback dialogue session which I organised in Freetown, May 17th, 2014. 156 conducting a full community monitoring cycle, which included three ‘compact meetings’ at each of the twenty-five sites in Tonkolili. Each site was centred on a health centre and the surrounding ‘catchment communities’ which are home to the people who frequently use that particular health centre. For the compact meetings, the
CSOs were responsible for bringing between 50-80 ‘healthcare users’ to each meeting: five individuals from a maximum of sixteen catchment villages. Each group of five community representatives had to include a traditional birth attendant (TBA), an adult male and female community representative and a male and female youth representative. During the interface meeting, the service provider representatives were all employees of the health centre, excluding the TBAs who work as volunteers. In advance of the interface meetings, the implementing agencies were required to collect community-based data and conduct focus group discussions with the community representatives. This data was used to compile clinic specific scorecards, which were discussed during the interface meetings.
The CM method contains several unique components:
CM is the only method in which the social pressure of the community alone is
used as the key leverage tool to encourage health workers to improve their
performance.
The use of score cards within this method is specifically designed to address
the information asymmetry that naturally exists between health workers and
healthcare users.
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5.4 Assessing the Community Monitoring intervention
This section provides an examination of the implementation of the Community
Monitoring with scorecards methodology. It starts by presenting the findings from the health worker interviews and the focus group discussions. This section is followed by additional observations about the intervention, which became evident during the field visit. These are based on my observations, interviews with key informants and staff from the implementing agencies.
5.4.1 Impact –from the health workers’ perspective
During the interviews I asked health worker a range of questions about the differences between delivering health care before and after the introduction of the free healthcare initiative (pre/post April 2010). The interviews also included several questions about the health facility, which allowed me to gain an understanding of the constraints under which the healthcare workers operate. For example: the community monitoring sample of six clinics included four clinics where health workers were not provided with housing and lived in one room inside the clinic (which often had no more that 2-4 rooms), at times sharing this room with a second health worker. In Tonkolili, staff accommodation was particularly scarce, as much of it was destroyed in the war, and unlike the clinics, not many staff houses had been rebuilt. All health workers (100% of total sample) lacked a functioning bicycle or motorbike which could be used to travel to outlying communities for ‘outreach work’ (vaccination and check-ups in catchment communities). Half of all the clinics lacked refrigeration, often due to a lack of funds
158 to repair or maintain the solar-powered fridge. Four out of the six clinics even lacked a properly protected water source.
Most striking was the number of staff who were listed as ‘working at the clinic’, but who were not on the government payroll. Sierra Leone calls its government run clinics
Peripheral Health Units (PHUs) and divides them into three sizes: The largest are
Community Health Centres (CHCs); medium sided ones are called Community Health
Posts (CHPs) and the smallest are Maternal and Child Health Posts (MCHPs). CHCs may have up to four or five staff on payroll. These facilities are usually found in so- called ‘district headquarter towns’, serve a community of up to 30,000 people and are a referral facility for treatments not offered by smaller clinics. CHPs are medium sized clinics and serve a catchment community of up to 10,000. These clinics usually have one or two staff on payroll. The majority of the interventions witnessed for this researched focused on CHPs. MCHPs are the smallest health facilities and are supposed to serve no more than 5,000 people providing basic medical services such as vaccinations and the treatment of minor illnesses. Since the introduction of the FHCI, many MCHPs have created space for a birthing room and encourage women to give birth at the facility. MCHPs often have only one staff member on payroll, especially in remote locations.
The majority of the clinics I visited during the field research, with the exception of the larger facilities (the CHCs), were managed by just one or two paid staff. It appeared that a group of 48 graduates from Tonkolili’s health worker training course in the district capital Magburaka had been sent on work placements at clinics throughout the district, with a view to being permanently employed there, but that none of these individuals had been added to the payroll yet. These ‘trainees’ had been working
159 without any payment for at least six months, and in two cases acted as the only medically trained staff member of the clinic. When asked how she can survive without salary, one trainee replied “I am just managing”, adding later that people from the nearby village bring her food and firewood for cooking (HW37). Overall, the person in charge usually reported that their clinic had one or two trained medical staff on payroll, possibly one unpaid trainee, one unpaid vaccinator and up to ten unpaid TBAs who worked shifts at the clinic. A quarterly ‘Performance Based Finance’ payment was supposed to be used in part to pay the volunteers a stipend. It was clear that this was often judged as not enough, and there were delays in the transfer of these funds and a lack of clarity about who should be paid how much.
When I asked the health workers about the CM intervention, the majority (83.3%) were positive about the project and often mentioned that it had been a good opportunity to pass on health messages to the wider community. That particular sentiment was not only expressed by all the health workers who recalled their involvement in the CM intervention, it appeared to be central to everyone’s perception
(health workers, facilitators and service users alike) of what the CM intervention was intended for. When asked what behaviour changes the CM interventions had brought about, the health workers stressed the patients’ behaviour changes. Many health workers suggested that after the CM meetings patients sought care more promptly, reduced the use of herbal medicine and reported an increase in women coming to the clinic to give birth.
Only after repeated prompting, some health workers remembered that they had also committed to changing their behaviour after the CM meetings. In response to complaints about absenteeism (a complaint found in 4 out of the 5 compact
160 documents38 reviewed in detail), one nurse promised to notify the community and the village headman before leaving. In two other cases, a nurse promised to coordinate with a second health worker to reduce periods where the clinic would be left unattended. Overall, the compacts demonstrated that the interface meetings had resulted in community representatives undertaking the majority of the behaviour change promises, not the health workers. In each of the five compacts I was able to review, 3-4 of the problems discussed resulted in remedial actions that the community had to take (stop using native herbs, come to the clinic more regularly for vaccinations, ante-natal care and delivery, use bed nets properly and construct more latrines in the villages). Per compact there was usually only one issue that the health worker needed to address – and even then, it was often a solution that did not match the actual problem. For example, when community representatives complained about being charged fees for free health services, the ‘solution’ found was that ‘the nurse has to explain in more detail why she charges for the purchase of record books or soap’ or, in one other case, ‘the nurse should explain the free healthcare guidelines better’.39
One health worker (HW49) described the CM intervention, including the drawing up of the ‘community compact’ as follows: “We made a letter together with community…
[it said that] the TBAs should not conduct any delivery at home. Nurses shall give help to all people in the categories of FHC, under no cost recovery.” When prompted about changes the health worker had committed to, a different health worker explained
(HW51): “I gave them [members of the community] my phone number, patients can call me if there is problem, if I go for outreach, I inform them. They now come for
38 The large majority of compact documents were not retained. I was only able to find five compact documents in Concern’s office in Mburaka (out of the 25 compacts that were compiled in Tonkolili), and only some of those matched the clinics I visited. The compact information I present here is therefore not based on the clinics I visited but on the samples I was able to access. 39 In all three cases, the solution found seemed to imply that the nurse was not condemned for charging, but the community seemed to have been blamed for not understanding why they were being charged. 161 cleaning, made a fence. They also know who [needs] to pay in hospital. That is the most important, because they didn’t know about who gets the free healthcare.”
The carefully crafted scorecard component received little attention during the interviews; only one health worker recalled the scorecards. She explained how she challenged the community over the low score she received on certain criteria, although she could not remember which. She felt that the meetings helped her to be more appreciated by the community, before adding that she had learnt to be friendlier with the patients.
Based on the interviews and having read a sample of community monitoring compacts, it was clear that the health workers appeared to have found the intervention a useful experience. However, none of the health workers’ responses matched those from other community monitoring interventions (Bjorkman and Svensson 2007, Ho et al 2015), where there was clear evidence that the CM process led to service providers really being held accountable for the service they provided, and where both service providers and service users forged working relationships based on a mutual understanding of the constraints the others faced.
Summing up the findings of these interviews, most health workers highlighted the fact that they were able to provide information to the community and to mobilise the community to help with regular cleaning of the health centre, its compound and some of the access roads or paths that lead to the clinics. There were also several mentions of
‘the community now knows who is entitled to free care’.
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5.4.2 Impact – from the health service users’ perspective
The impact of the CM intervention from the health users’ perspective was established through the focus group discussions. In each of the locations where I interviewed the
‘in charge’ of the health centre about the CM intervention, I also conducted a focus group discussion with a group of women who routinely access a particular health centre.
While it was evident that ‘acting accountably’ involved much more than ‘not charging women for free healthcare’, it quickly transpired that ‘paying for free care’ was the problem the women most wanted to talk about during the CM focus group discussions.
This was not surprising: three years earlier women they been told that healthcare was going to be free for them during pregnancy and while lactating, and for their children under the age of five. The fact that this didn’t materialise was a major disappointment, often perceived as a terrible injustice and practically, it remained a barrier to proper access to healthcare.
Because the issue of charging for free care came up with such frequency during the focus group discussion, I decided that this could serve as one natural proxy indicator40 of the success of the social accountability interventions. For this reason, each of the case study chapters will contain the same graph which will show during how many focus group discussions the problem of charging was raised, and will serve as an indicator that signals whether or not charging was mentioned in each of the intervention-specific sub-sets of focus group discussions.
40 There were of course a range of indicators that provided evidence of the success or failure of each social accountability intervention; such as ‘the community attending the clinic more often’, ‘the health worker making a greater effort to treat patients’, etc. However, the problem with charging appeared to be so fundamental to the way women perceived their access to healthcare, that this was an obvious choice in terms of an indicator that needed to be highlighted. 163
Figure 6: Illustration of incidence of alleged charging for free care, raised during FGDs
10 9 8 7 6 5
4 3 No charges for free care 2
clinic 1 mentioned 0 Problem with charges for free care discussed Number of FGDs aboutnearby
During the implementation of the CM intervention, the villages surrounding the clinic had all provided five representatives to take part during the three ‘interface meetings’ that were held. It therefore seemed important to ensure that at least one of these community representatives was part of the focus group discussion, so that more could be learned about what happened during these meetings.
The very first CM focus group discussion was conducted close to the clinic and it was dominated by one or two elderly women (it later transpired that one was a TBA, the other the chairperson of the Facility Management Committee) who did not want to hear anything bad about the health workers they assisted. It was clear that these elderly women dominated the conversation so much that it became impossible for others to answer the questions, as the women kept repeating that all the interviewer needed to know was that the village lacked a water pump. The interview was abandoned. This was not the only interview in which TBAs ‘working’ at the clinic dominated the conversation; this sample includes another focus group discussion that was overshadowed by the local TBA. It was clear that the TBAs who worked at their local clinics had good reason to cover up the charges that were being levied; these were
164 often put in place to provide funds to pay for people such as the TBAs who worked in clinics without being on the government payroll.
In my reflective diary of the field visits to Tonkolili (dated 22 and 23 Nov 2013) I wrote extensive commentaries about the TBAs; these ranged from my efforts to understand the role of TBAs at clinics, observations about ways in which I might ensure that no TBAs attend my healthcare user focus group discussions and working out that the claim that TBAs can survive on the money they receive as a share of the performance based finance was completely unfounded:
[…] this means that the TBAs, who can work anything from an ‘every other day’- shift to a full week on duty (sleeping at PHU) get paid about 12 US$ per 3 months! It is very unlikely that anybody would accept such payments, especially in Sierra Leone - people seem pretty assertive when it comes to payment! It is clear that there's an elaborate system of under the table payments being levied that ensures that the clinic ‘volunteers’ get paid, just like they used to, pre-FHCI.
During each of the six focus group discussions, the conversation opened with a question about how the interviewees rated the free healthcare provision. In all six cases the discussants indicated that they received little or no free care. On one occasion the opening question was met with complete silence, as every member of the group waited for somebody else to explain the reality. During each of the six focus group discussions the women insisted on detailing the types of payments they were requested to make to the healthcare workers at the local clinic. It was clear that there were relatively fixed prices for a lot of items, most of which should definitely have been free.41 One of the conversations (FGD41) illustrated that while the women were not always asked for money outright, they nevertheless ended up paying: “When you go
41 It was impossible to verify if certain medicine should have been free, as the women could not explain exactly which items they had paid for, but it soon became clear that in most cases ‘all syrup’ (infant paracetamol, syrups to treat respiratory illness etc.) were charged for, while the most common types of syrups were definitely part of the basic care package. 165 into the clinic, you can bring a gesture to them [health workers] and if you do that, you can get the drugs free. If you don’t, you have to pay.” When asked what kind of gesture was required and if 1000 Leone [US$0.23] would be sufficient, the women answered: “Well, they don’t say how much you need to give! But, yeah, maybe you can get some medicine after that.”
It was not only medicines that were being charged for. Some women reported being charged just for a child to be seen by the nurse, for vaccinations or malaria tests.
Pregnant women are supposed to be given free ante-natal care record cards, on which her visits to the clinic and pregnancy-related statistics are recorded. Similarly, all newborn babies are supposed to be given a vaccination card at birth to ensure that a record is kept of all the vaccinations the infant receives. Both these cards turned out to be subject to significant charges, with more than half of the women in the focus groups reporting the need to pay for these cards. In some cases subsequent treatment would be free, once the ante-natal, vaccination or growth-monitoring card was produced.
There was a lot of confusion about which medication pregnant women or children under five should be given for free, but across the board it was clear that the women usually paid for all but malaria medication or some paracetamol tablets. Several (33%) focus groups detailed how treatment and medicines were initially free when the FHCI was introduced, but in most cases this happened only once. “The free medicines have run out” was one of many reasons for charging that health workers offered as an explanation for demanding 5,000 or 10,000 Leone (1-2 US$). Charges were introduced as, so health workers claimed, the supplies of free medication ran low.
166
While there were undoubtedly many problems with the free medical supplies42, it was unlikely that women who attended the clinic monthly never came at a time when the stocks had been replenished.
A patient (FGD57) recounted how she had asked a health worker if there was any free healthcare medicine available at the clinic to treat her sick baby, she explained: “The nurse said to me ‘free healthcare, free die’” - making it clear to her patient that she should not be expecting free healthcare handouts. This practice clearly undermined the community’s trust in the health workers, as patients explained during the focus group discussions that they were aware of quarterly deliveries of free medicines, which were, as mandated by the health authorities, always witnessed by the Facility Management
Committee, the village chairman and many villagers. When women were told a week or two after such a delivery that all the free medication had run out, they generally knew they were duped. Many of the women consulted during the focus group discussions were cynical about the health workers who worked in their local health facilities. “We thought that free healthcare would solve our health problems, but the changes have been minimal”, one woman said (FGD33). Asked why the women didn’t challenge the nurse when she demanded money, considering they all knew that she should not be charging women for treatments and medication to treat their children under five, many shook their heads. It was clear that the women were all too aware the nurse had the power to withhold medical care when they needed it most, so their only options were to pay or to walk away and go without treatment.
When questioned about the community monitoring meetings, the focus group discussants nevertheless rated them as useful. All six groups listed a series of health
42 Continued irregularities affecting the distribution of medical supplies has plagued the FHCI from the beginning, as documented in Amnesty International 2011; Bandhari 2011; IRIN 2012, Maxman 2013, and others. 167 education messages that they had heard during the meetings, some of which had been new to them (e.g. clearing away receptacles that can hold stagnant water from near the house to prevent malaria), and others that had simply been forgotten (wash hands before every meal). The standard messages the health workers insisted upon during the interface meetings included: attending the clinic earlier with sick children, come for all vaccinations, don’t give birth at home, don’t use traditional herbs to cure illnesses and don’t buy medication from ambulant drug salesmen.
One focus group reported that the meetings had improved the relationship between the community and the health workers, while in another community the women, supported by the TBA, resolved that they would no longer give their children any native herb cures. With regards to how the health workers’ behaviour had improved, the focus group discussants reported that in one case, a health worker had started to give health education talks during vaccination days. The same health worker had improved the toilet facilities for the patients and had started to ensure that the trainee health worker would be available at the clinic whenever she was absent. The other five groups did not report any improvement to the health workers’ behaviour.
In one of the catchment communities, the people who attended the community interface meeting admitted that they had not brought up any of the problems with the health workers during the meeting. “I wanted to speak out”, a woman who had been a community representative during the CM interface meetings admitted, “but the people from the other catchment villages told me not to talk. We said all was good with the nurse, even though it is not. If you give birth, you need to carry 10,000 Leones
[US$2.30] or you’re in trouble.” When asked if she would speak out if another meeting was held, she said without doubt “yes, this time I would tell them.” I asked her why.
168
“Because the suffering has increased since then. The lactating mothers suffer, they don't get free medicines. I am ready to speak up” she added (FGD32).
In two focus groups, the participants expressed their disappointment about the fact that the health workers had not kept the promises they had made during the community monitoring meetings (FGD50, FGD53). In one case, a health worker had committed to be kinder to the patients and not shout at them, while another had said she would reduce the number of days that she was absent from the clinic and not charge for care that should be free. Health workers’ failures to honour compact commitments appears to have had a disempowering effect on some of the women (and several of the men too) who attended the interface meetings, making the health workers’ position of power even more evident. Several focus groups discussants expressed their desire to do something about the charging, but admitted they were afraid to upset the nurse. On one occasion the women openly expressed their helplessness, explaining that there was nothing they could do, citing the fact that they were all illiterate43 as a reason for being unable to speak out (FGD62).
5.4.3 The Community Monitoring implementation’s challenges
Several additional findings are worth highlighting. Most of these came to light through interviews with Concern staff, the implementing CSOs’ staff and after reviewing programme documents.
43 Out of the 6 women who participated in focus group 62, one was in the senior cycle of secondary school, one was in the junior cycle of secondary school, 1 was in primary education and three never went to school. All six were either pregnant, lactating or the mother of a child under the age of five and none of them could read or write. 169
While examples of community monitoring interventions from other countries (Green
2011, Holland et al 2009, Hossain 2009, Shah 2003, Singh and Shah no date) usually focus their attention on the shortcomings of the health workers and the building of trust between the clinic staff and the community, it transpired that this was often not the case during this intervention. The surprising lack of the expected outcomes was most likely caused by weak facilitation, and a lack of understanding of the problems faced by the community.
In one of the first quarterly narrative reports by Concern, among its recommendations is the need to further build the capacity of the community monitoring facilitators, expanding their training to seven or eight days instead of five. In one of the reports from Concern’s partner agency it is noted that “the facilitator needs to internalise the issues well before facilitation” (OPARD 2012). This, it seems, was a huge part of the problem: during interface meetings the facilitators were often faced with complaints from the community and denials from the health workers. Most facilitators appear to have sided with the health workers, believing their implausible explanations for the problems that were raised and accepting, at times, even more far-fetched solutions. In one compact, the solution for the complaint about charges demanded for giving birth at the clinic read “nurse to sensitise community on preventative measures including injections [i.e. contraceptives]” (Concern 2012). From reading a sample of community compacts, it is clear that facilitators often failed to understand the seriousness of the complaints the community put forward.
Certain design faults that plagued the CM implementation became apparent after it was too late to change the implementation (keeping the implementation constant was important for the RCT). A key example was the fact that many communities sent
170 different people to the three interface meetings, despite the fact that the guidelines stressed the same individuals should attend -in order for them to recall the last meeting and hold the health workers to their ‘community compact promises’. The per diem for community representatives was of such magnitude (20,000 Leone [US$4.60], which is close to a week’s income in rural areas) that it appears to have been decided in most communities that the opportunity to earn such a windfall should be shared. This was highlighted by Concern staff and was mentioned in several articles and chapters that were published about the interventions (Grandvoinnet et al 2015, Hall et al 2014).
A second design flaw was related to the nature of the scorecard information. During every community monitoring intervention, ‘interface meetings’ between service providers and service users are designed to be the events that help to transform the relationship between the two groups. The scorecards used in these interventions are intended to facilitate or enhance the dialogue regarding the health services that are provided by the target clinics.
In order to compose a scorecard for each clinic, the implementing agencies were required to collect considerable amounts of information. CSO staff had to travel to the catchment villages to collect data for six indicators: infant, ‘under five’ and maternal mortality rates, the percentage of women who attended ante-natal visits at least three times, the number of deliveries that took place at the health centre and on the percentage of children that were fully vaccinated.
In advance of the first interface meeting CSO facilitators held focus group discussions among the healthcare users to establish three additional scores for the health workers’ behaviour: absenteeism, politeness and charging for free care, which were the final three indicators for the score card. The first six scorecard indicators allowed health
171 workers and the community representatives to compare the data collected by the clinic with the data reported by the communities. The objective of including these two data sets was to generate a debate about ‘the community’s health status as reported by the community’ versus ‘the community’s health status as reported by their local clinic’.
The designers of the programme had expected that the variance in the two data sets would create some indignation about the fact that the clinic data only captured a percentage of, for example, the mortalities that occur at community level, but both interview data and reports suggest that this was not the case. The community representatives were aware that there was an enormous disconnect between the villages and the local clinic, and nobody expected the clinics to have accurate data.
The second problem with the scorecards was the second set of indicators, gathered during focus group discussions in advance of the interface meeting. A Concern staff member (KI76) recalled that their programme staff (who carried supervisory visits to check on the implementing agencies) had had difficulties collecting scorecard data about the health workers’ behaviour. The community representatives’ focus groups
(during which the scores were collected) were held on the day of the interface meeting, close to the clinic. This meant that representatives from different communities were grouped together for the purpose of generating joint scores for the healthcare staff’s behaviour regarding politeness, absenteeism and charging for free care. Because individuals did not know each other, many participants decided not to give negative scores because they were worried about possible repercussions.
During an interview with the World Bank employee who was heavily involved in the design, he was open about the fact that its design borrowed heavily from a well know
RCT that trialled community monitoring in Uganda (KI121). However, he conceded,
172 what works in one country doesn’t always work in another, and it was a challenge to get the small details right. This lack of contextual awareness was clearly visible in the design: The effort involved in bringing about the ‘health worker-community interface meetings’, turned out to be overly time (and budget) consuming. The RCT guidelines stated that CSO staff had to travel to between 10 and 16 catchment villages per clinic
(located up to 20 km from each health centre, often on roads that are only accessible by motorbike, bicycle, or on foot) to collect score card data and ensure that five people were selected to represent their community during the interface meetings. Concern’s four implementing CSOs covered twenty-five clinics between them and held three interface meetings per clinic, so the schedule was punishing.
Much of the implementation period fell during Sierra Leone’s rainy season, which rendered many dirt roads impassable. The logistics of the meetings themselves were challenging too: it was clear that the participants needed at least one meal during the meetings, so the organisers had to provide food for up to 90 people, accommodate some participants from the remotest communities overnight, carry large amounts of cash and keep a log of the travel compensation it paid to each individual. It is therefore hardly surprising that the facilitating CSO staff appear to have focused primarily on the logistics of the meetings rather than on ensuring good quality dialogue.
It was not only the logistics of the CM intervention that were considered challenging by those who implemented it. During interviews, the directors of all three INGOs that worked on this World Bank programme cited a range of problems that hampered the success of the interventions (KI77, KI111, KI113). Before the full implementation started, a smaller pilot project was implemented with a view to ironing out any problems in the design of the programme. The pilot project appears to have led to
173 some rationalisation of the programme, but all three directors argued that it remained overly complicated for the Sierra Leone context: the funding provided to implement the entire programme was tight. Funds needed for adequate supervision of the implementation were underestimated and the NGOs that worked with local partner agencies incurred additional training costs due to the low levels of capacity and the high turnover of CSO staff.
The problem of low capacity and high turnover of staff in CSOs is not uncommon in
Sierra Leone. A report that assessed the capacity of Civil Society in Sierra Leone in
2014 noted: “[…] staff members of most such CSOs receive salaries that are tied to short-term projects. Staff can be relieved without termination benefits when an organisation’s project portfolio reduces” (Campaign for Good Governance and
CIVICUS 2014, p. 20). Concern staff admitted they had faced a number of challenges to find the right implementing partners for this programme. The capacity of the
Tonkolili-based CSOs that replied to its invitation to tender for the intervention was low. One Concern staff member added that she questioned her organisation’s commitment to working with local partner organisations in an operational environment such as Sierra Leone. She favoured a ‘direct implementation approach’ in which her organisation could recruit local staff for the implementation of programmes and have greater oversight, quality control and ability to dismiss non-performing staff (KI76).
During the research it became evident why the Concern staff member had made such remarks. Interviews with two of the directors of the implementing CSOs demonstrated that they had limited technical knowledge and neither agency specialised in health nor citizen engagement programming. One of the four local partner agencies was headed
174 by a director44 who was also a full-time employee of Tonkolili’s District Health
Management Team (DHMT). Tonkolili’s DHMT was the authority from which
Concern and the World Bank would have had to obtain permission for the programme’s implementation. While there was no suggestion that the approval of the project in Tonkolili had been conditional to this particular CSO receiving one of the implementing contracts, this potential conflict of interest clearly existed. It also meant that the director, who explained during our interview that he spent considerable time on the implementation of the Concern/World Bank programme, was obviously double- jobbing: either absenting himself from his government job to work for the CSO, or visa-versa (KI75).
5.5 Analysis
The following section provides an analysis of this intervention, using the analytical framework introduced in the methodology chapter. The analytical framework contains four components: redressing information imbalances; citizen participation; power and political awareness; and staff motivation.
5.5.1 Redressing information imbalances
Social accountability interventions can vary greatly in design. Even within each design’s component there can be a difference in approach. There are, for example, several ways to approach ‘redressing the information imbalance’. Firstly, and most simply, a social accountability intervention can provide communities with objective
44 He described himself as ‘interim director’, but had held that post for eight years (KI75). 175 information that relates to the service that is supposed to be delivered. Such information is often readily available45, but may not always have reached communities.
This kind of information usually includes details about citizens’ entitlements and service standards that should be adhered to, such as opening hours or the number of staff who should be at work in a particular health facility. I call this type of information component ‘info in’.
The Tonkolili-based Community Monitoring intervention did not have an ‘info in’ component. It is likely that the designers of the intervention assumed that much of the basic entitlement information had already been provided by other civil society organisations that had conducted information campaigns during the launch of the free healthcare. The evidence suggests that many of the healthcare users were still unclear about the details regarding their free healthcare entitlements and that an additional
‘info in’ component would have been useful.
Instead of ‘info in’, the CM intervention focused on an information component that I call ‘info out’. The CM’s info out component was the scorecard system. As discussed, the scorecards were designed to generate debate regarding the quality of healthcare services. The scores of the scorecard were based on data gathered from the target population. This data was first collected (hence the name ‘info out’), then aggregated by the implementing agencies, and subsequently presented back to the communities in conjunction with additional information – the health centre-based data capturing the same indicators.
45 This is not always the case, there is a substantial body of literature about the use of Freedom of Information laws, which is sometimes used to obtain information on budgets or contracts related to public services. 176
Various types of ‘info out’ components work on the assumption that individuals may be aware of their own situation, but they are unable to collect large amounts of data and aggregate it to get an overview of the situation. The designers of the CM intervention assumed that the target communities would be dismayed to learn quite how great the discrepancy was between the community-level and clinic-based data on, for example, infant mortality. However, it appears as if very few individuals who were presented with the scorecards were surprised at all. Many seem to have taken the view that it was obvious that clinics were unaware of what happened in the villages; health centres were not considered to have a mandate to record deaths in their locality, unless they occurred on the premises.46
The nature of the information that is provided as part of the ‘info in’ or ‘info out’ has a significant bearing on the impact of this component. A follow-up study to the 2007
Björkman and Svensson RCT on which the design of this CM intervention was based, showed that when communities participate in interface meetings without having been given clear information about entitlements, health workers’ absenteeism (measured by
NGO staff), waiting times, etc., the compact “[…] mostly identified issues that required third-party actions; e.g. more financial and in-kind support from upper-level authorities and NGOs and a timely delivery of medicines from the center”. When health user groups received specific and relevant information about their local services, interface meetings produced compacts that “almost exclusively identified (88 percent on average) local issues, which either the health workers or the users could address themselves, including absenteeism, opening hours, waiting time, and patient-clinician interactions” (Björkman, Svensson, de Walque 2014, p 20).
46 It was not clear if health facilities in Sierra Leone are required to collect data on all deaths that occur in their catchment communities, but it certainly was not common practice to do so. 177
In conclusion, the CM’s redressing information imbalance component was largely ineffective. The information (i.e. the difference between village-level health indicators and the same indicators recorded at clinic level) did not address any actual information gap. The discrepancy between the two data sets was not relevant, and it therefore failed to generate a debate about the quality of healthcare the communities received.
Had the information been more relevant, it may have helped to redress the information imbalance within the community, and herewith the power imbalance. In an ideal scenario, a CM intervention would have contained an information component that provides community representatives with tools to produce evidence that health workers provide inferior services, were absent or charged for free care. A much simpler approach to redressing the information imbalance would have been more appropriate in this case, and could have shifted the compacts’ emphasis from focusing exclusively on behaviour changes the community needs to make to changes that health workers need to make.
5.5.2 Citizen participation
The community monitoring intervention was the methodology that contained the largest citizen participation component of all four interventions in the sense that it repeatedly brought large groups of citizens in contact with health service providers.
The objective of the large ‘interface meetings’ was that mutual commitments would be made in open community meetings “[…] in order to ‘bind’ state actors through the sanction of public shaming should they fail to comply” (Grandvoinnet et al 2015, p.237). In reality, neither of these objectives were achieved. It was clear from the sample of compacts I reviewed, that health workers had dominated the community 178 meetings and had ensured that they were ‘bound’ by very few mutual commitments.
The large majority of behaviour change commitments were made by the community, not the healthcare staff. The meetings seem to have done little to improve the relationship between healthcare users and providers. As for the sanction of public shaming, this too appears to have been absent, as health workers seemed to take little note of the opinions of the community.
The only evidence that speaks of the CM intervention’s designers’ understanding of the challenges of working with community-based feedback mechanisms can be found in a write up about the intervention in Grandvoinnet et al 2015: “[…] a mutual accountability approach was emphasized, with intermediation by outside facilitators to help to enforce commitments. Citizens readily embraced this approach, internalizing and localizing commitments by enacting bylaws, appointing inspectors, and introducing other (often punitive) measures to ensure compliance at the village level”
(2014, p. 239). What the text did not emphasise was that this approach only helped to ensure village-level compliance with the compact promises. There is little evidence that the outside facilitators helped to enforce the health workers’ commitments. The
CM method facilitated the promotion of improved health related community practises, but it did not create the community cohesion that would have been needed to tackle the health workers’ behaviour.
By examining the citizen engagement component of the intervention, it is easy to see how the programme design could be criticised for promoting tokenistic citizen participation. The decision to bring together five individuals from up to 16 catchment villages undermined the cohesion of the citizens who were brought together for the citizen-service provider dialogue. The evidence suggests that the representatives from
179 different communities did not know each other when they arrived for the interface meetings and the focus group discussions that were held prior to that. Because the community representatives had no time to get to know each other, they were often unwilling to reveal the truth about some of the shortcomings they had been facing, leading to health workers receiving high scores for behavioural issues that were often in need of addressing.
A close examination of who was selected to attend the interface meetings shows that several design constraints hampered the intervention’s chance of achieving genuine democratic participation. First of all, the small numbers and the prescribed nature of the five community representatives who were to be selected (one TBA, a male and a female youth representative, and a mature male and a female), undermined any chance of a diverse range of representatives. When NGO staff arrive at a community to seek representatives to attend a meeting, a community often selects its most powerful or well-off individuals to, on the one hand, create a good impression, and on the other hand, to negotiate the best deal for the community - in case there is a deal to be negotiated (Cleaver 2001). While this is rational behaviour that cannot be faulted, it does also mean that when an NGO asks for community representatives, it will be exactly these kinds of respected leaders or gatekeeper types who are selected. This immediately reduces the chances that the voices of the more marginalised members of a community can be heard.
The inclusion of the traditional birth attendants in the groups of community representatives added an additional challenge throughout the interface meetings.
Concern staff explained that they had asked the World Bank if they could change the programme design and include the TBAs in the health workers’ dialogue, as many
180 worked in the clinics. On several occasions, Concern staff highlighted, TBAs had attended focus groups in which community representatives scored the health workers on their behaviour, only to reveal to the health workers who had ‘told on’ the clinic staff and given them bad marks (KI176).
The awarding of travel compensation to attend the interface meetings further complicated matters. Hall, one of the designers of the CM intervention, who attended a number of the interface meetings and authored a case study that reflects honestly on its successes and failures, wrote “[…] reimbursements [of travel allowances] entailed their own set of challenges, however, including the ‘capture’ of rents by more powerful members of villages. Further, many villages chose to distribute the rents by alternating who would attend meetings, with significant implications for the continuity of discussions in meetings where the compacts were concluded” (Grandvoinnet et al
2015, p. 240).
In conclusion, the CM method did not achieve broad-based participation; the implementation guidelines’ strict instructions regarding who should attend the interface meetings were too prescriptive and the generous per diem only seems to have undermined chances of genuine citizen engagement further. Participation was achieved in the sense that the required number of people were brought together, but the community-health worker dialogue meetings did not lead to the collective action which the intervention’s designers had hoped for. The meetings seem to have helped health workers to reinforce useful messages on preventative care and on the importance of attending the clinic, but that was not the objective of the community monitoring intervention.
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5.5.3. Power and political awareness
The project design of the entire World Bank randomised controlled trial, i.e. the community monitoring and the non-financial award interventions, shows clear evidence of awareness of the political economy of Sierra Leone as an operational environment. However, the actual design of the intervention does not reflect this awareness and overall, the programme designers seem to have struggled to communicate the need for power and political awareness to the agencies it contracted to carry out the implementation. It is clear that at local level, the CSO partners showed much less power awareness, especially when it comes to the facilitation of the community monitoring interventions.
The empirical evidence suggests that the manner in which the CM interface meetings were held was wholly inadequate in terms of dealing with the unequal power balance between the health workers and the community. The small sample of available community compacts show that very few of the issues that related to the health workers behaviour were raised, and whenever they were, the meetings’ facilitators were willing to accept either unsubstantiated excuses –such as “I used cost recovery medicine to save a life and therefore I had to charge for the medicine I prescribed”. If a complaint was not brushed aside by the excuse offered, a number of improbably solutions were also allowed to be documented; advice on contraceptives was suggested to solve the complaints about the charges for facility deliveries, and general complaints of charging for free healthcare were solved by asking the health workers to explain the free healthcare entitlement rules again (implicitly suggesting that any charging was justified because the patient was not eligible for free care and therefore the health worker was right to charge).
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To some extent, the CM implementation seems to have repeated some of the mistakes that many early social accountability interventions displayed. While at the highest level there was a strong conceptual awareness of the politics and power dynamics inherent in programmes that aim to improve accountability (especially in highly corrupt and rent-seeking environments), yet, at the implementation level, where it mattered most, there is no evidence of power awareness on the part of those who facilitated the most crucial parts of the intervention. Instead, the CSOs implementing the activities seem to have been allowed to focus on merely the logistics of ‘doing the project’, or what Joshi and Houtzager refer to as “ ‘mechanisms’ or ‘widgets’ […] which tend to depoliticize the very processes through which poor people make claims”
(2012, p. 145). The way the interface meetings were planned and executed are reminiscent of Eberlei’s description of an ‘events culture’. Eberlei cautions that “Many public officials seem to believe that all that these [citizen engagement] concepts imply is the holding of a series of hearings, workshops and consultations, not the establishment of a long term participatory dialogue with civil society” (cited in
Ackerman 2005b, p. 17).
The designers of the CM intervention displayed a striking lack of political and power awareness with regards to identifying key power brokers (chiefs, village leaders, district health officials, etc.) who could have influenced the outcome of the intervention. It is only after the RTC had been completed that the following suggestion was made in terms of what may have improved the effectiveness of the intervention:
The quality of engagement differed considerably from clinic to clinic, depending on the skills of the NGO facilitators and on local-level power dynamics. In general, the compact interface excluded chiefs and district officials, an omission that may have limited its usefulness. Greater inclusion might have improved the overall results of the intervention but would have run the risk of inviting local elite capture. Despite attempts by external facilitators to steer the discussion delicately, in some instances the
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meetings were captured by elites whose interests were not aligned with those of the broader community. (Grandvoinnet et al 2015, p. 243)
The RCT’s data analysis provided interesting results, it showed community health indicator improvements attributable to the CM intervention, but these were primarily of the kind I would describe as ‘community-initiated change’. The CM interventions appear to have resulted in a but measurable small increase in the utilisation of government clinics, some minor increases in numbers of births at health facilities and a slightly improved nutritional status among children. When it comes to changing the behaviour of healthcare staff, the intervention seems to have been less successful; immunization, antenatal care, absenteeism, and staff attitude were not affected by the
Community Monitoring intervention (IPA et al 2015, p. 31). Grandvoinnet et al suggest why this may have been so:
Nurses also often had little incentive to act or to improve their behavior. With limited monitoring, the costs of failing to comply with government policy were low, and the potential for rent capture was high. Given their control over drugs, treatment, and other key health resources, nurses are significant power brokers in their communities. From this position of power, they are capable of co-opting even the accountability committees that are supposed to oversee their work.
(Grandvoinnet et al 2015, p. 237)
An additional weakness with regards to the CM designers’ lack of power and political awareness was their unquestioning faith in the capacity of the organisations that implemented the interventions. The RCT design involved a long chain of task delegation (see figure 5) from the World Bank to the three INGOs, and in turn to subcontracting CSOs, and there were very limited funds for adequate supervision. The field research suggests that facilitators, and even some of the more senior members of the implementing agencies, failed to internalise the objectives of the community 184 meetings they organised. Some may not have been communicated these objectives adequately or maybe they cared too little about the outcome of the meetings beyond the fact that they achieved the required attendance, paid the stipulated travel allowances47 and wrote the necessary donor reports. As Devarajan et al suggest:
[…] strategies and interventions in this regard need to be cognizant of underlying political economy drivers of failures in accountability. In political economy environments characterized by high degrees of clientelism and rent-seeking, such as are widespread in the Africa region, an unqualified faith in civil society as a force for good is more likely to be misplaced.
(Devarajan et al 2011, p. 3)
In this case it was clear that the CSOs that implemented the intervention did what was required of them, but little else. In the case of a social accountability intervention it is necessary that facilitators do more than that, they need to believe that they can bring about lasting change. If facilitators assume they are hired to bring people together, pay per diems, run through a list of questions and go home again, little can be achieved.
5.5.4 Staff motivation
While there was little in the CM programme documents that pointed explicitly to staff motivation considerations, social accountability interventions in general are thought of as being a ‘carrot rather than stick’- method, avoiding explicit punishment of unaccountable behaviour in favour of extracting voluntary commitments to behaviour change, through the use of social and peer pressure. Again, it is the final reports and case studies written after the event that provide the best evidence as to what the intentions of the programme were:
47 The director of one of Concern’s implementing partner agencies mistakenly referred to the two interventions (CM and NFA) his agency implemented as “the financial awards and the non-financial awards programme”. This seemed to accidentally reveal that the focus of his agency during the CM implementation had been on the ‘financial awards’, i.e. on the payment of transport allowances (KI65). 185
Meaningful engagement between citizens and state actors at all levels (local, district, and national) was poor at the start of the intervention. […] Earlier attempts to improve relations, which relied to a large extent on “peer monitoring” of health workers by either citizens or NGOs, resulted in tensions. Such monitoring exacerbated adversarial relations with nurses. Instead, framing the compact in terms of mutual accountability aimed not to point a finger at “bad actors,” but rather to bind the community and clinic staff together in a joint effort to support local development.
(Grandvoinnet et al 2015, p. 242)
As already pointed out in this chapter, many ‘community compacts’ show little mutual accountability but rather a list of behaviour changes that citizens signed up to, with limited commitment to change from the health workers. The health workers evaluated the CM intervention as useful with regards to the opportunity to inform community representatives on the types of behaviour that could improve communities’ wellbeing or to explain the rules regarding who can and cannot get free healthcare, but few were able to provide any information about changes they had promised to make. None of the health workers mentioned an increased motivation to do their job well, although some positive actions were noted by the citizens (e.g. one nurse allegedly shouted less).
Evidence from the field work offered the occasional glimpse of a positive outcome that appeared to have been prompted by the CM intervention: in one case, the communities’ complaints regarding a health workers’ absenteeism prompted a health worker to request a second health worker to be allocated to the clinic. This request was granted and the health worker reported that the CM meetings helped to bring about this change, which has made her working conditions easier and dramatically reduced the days when the clinic closed (HW51). Unfortunately, this was one of very few positive examples to have emerged from this section of the research. Overall, the field work and the reviews of this intervention published by IPA and Grandvoinnet et al suggest that the CM intervention did little to change health workers behaviour.
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The empirical research did provide a number of suggestions as to why it may have been difficult for a series of three meetings to improve health worker motivation. It was evident that health workers in rural Tonkolili provided care under difficult conditions. While the introduction of the free healthcare increased the number of health workers in the entire system, many of the smaller clinics remained staffed by a single health worker on payroll. The fact that health services were expected to be provided for free to those who most frequently use clinics, created significant challenges in terms of generating income for the volunteers that worked at each clinic.
It seems likely that many health workers were caught between two unsatisfying and demotivating choices; they could either work alone and adhere to the free healthcare policy, or add some informal charges in order to pay for the services of a vaccinator, a cleaner and several TBAs.
5.6 Conclusion
This chapter was devoted to the description and analysis of the field research that examined case A: Community Monitoring with Scorecards. I conclude that the intervention was unable to achieve its stated aim of improving healthcare delivery through the improvement of health workers accountability. Evidence from the focus group discussions suggested that health workers continued charging for care that should be free after the conclusion of the CM intervention.
Some interesting details have emerged about the CM methodology: the quality of facilitation of the community-health worker meetings undermined the chances of health worker behavioural change resulting from the meetings. While the health
187 workers seemed to have made little effort to improve their work practice as a result of the intervention, the CM intervention does seem to have been linked to an increase of local health facility usage in the areas where the intervention took place.
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Chapter 6 - Case study B: Non-Financial Awards
and control cases
6.1 Introduction
This chapter contains details about case study B, which examines the implementation of the Non-Financial Awards intervention. This intervention together with the
Community Monitoring intervention described in chapter five, made up the two methodologies that were compared in a randomised controlled trail led by the World
Bank between 2011 and 2013. Section 6.2 introduces the intervention, and locates it within the range of social accountability methods that have been reviewed for this study. Section 6.3 presents the field work data, collected from both the health worker and the health facility users, supplemented by personal observations and extracts from published reviews of the programme. Section 6.4 uses the analytical framework to examine the Non-Financial Awards methodology. Section 6.5 presents additional data that was collected in Tonkolili District: a series of interviews and case studies collected at six ‘control’ sites, where no social accountability intervention had taken place. This data is treated as if it belongs to one of the four ‘treatment’ cases: health worker interviews and focus group discussion data is presented first, and the data is subsequently examined using the analytical framework for social accountability.
Section 6.6 concludes. The setting of this case study, and the control clinics, is
Tonkolili District, which has already been introduced in chapter five.
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6. 2 Case Study B: Non-Financial Awards
6.2.1 The implementation of the Non-Financial Awards intervention
The Non-Financial Awards (NFA) method of the World Bank study was designed as a comparator method implemented alongside the Community Monitoring (CM) intervention, with a view to assessing, primarily, which of the two methods generated the biggest improvements in healthcare delivery (which was measured by the assessment of the health status of a randomly selected cross section of the community48). The NFA intervention was specifically designed as a top-down monitoring system, to test if it would have the same impact as the CM intervention, where the monitoring and pressure is originates from the community. The NFA method was called ‘Respect Pass Money’, Krio for ‘Hard Work Trumps Financial
Reward’ (IPA et al 2015, p.8). It ranked each participating clinic in a district on the basis of both clinic utilization data and user feedback. The goal of the intervention was to examine whether and how user feedback (in the form of a series of household interviews) could be integrated into a separate national performance-based financing program in the health sector, which previously only included quality and utilization metrics (IPA et al 2015).
The NFA intervention was primarily a competition among participating clinics, and rewarded health workers at both the best performing and the most improved facilities.
At the beginning of the intervention, the relative rankings of the participating clinics
48 IPA et al 2015, p. 11 elaborates on the RCT assessment methodology: “The effectiveness of the interventions was assessed through indicators of maternal and child health outcomes, clinic utilization, and the quality of services provided. More precisely, eight key outcomes were specified: number of children completing first year of required vaccinations, number of institutional deliveries, number of women completing fourth antenatal care visit, whether fees are charged for maternal and under-five health services, nurse absenteeism, staff attitude, number of maternal deaths, and number of under-five deaths. Furthermore, the effects of the interventions on clinic utilization and the nutritional status of under-five children were evaluated.” 190
(by district) were calculated, based on measures of performance: utilization of maternal and child health services, health worker absenteeism, staff attitude and the charging of illegal fees. The data collection for these scores was carried out independently of the four implementing NGOs, which were only provided with the relative ranking of the participating 25 clinics in each district.
The data that the clinic ranking was based on was gathered by an external agency called Innovations for Poverty Action (IPA). IPA did not reveal to the community that its data gathering was in any way connected to the NFA intervention that took place at the health centre. The objective was that the community would not be notified about the NFA competition, unless the health workers did so themselves. The intervention did not have an ‘info in’ component, the communities that used the NFA target clinics were deliberately left uninformed about the intervention, and were provided no other information about the free healthcare, exactly as the CM intervention (which did not have an ‘info in’ component either).
The NFA intervention used several unique components:
It was the only method that had no community participation component at all. This allowed for testing to see whether or not the social pressure and monitoring by the community had an impact on health worker behaviour. The information component of the NFA methodology was exclusively targeted at the health worker(s). Health workers were told how their clinic compared to others, but the implementing NGOs did not provide any information on the indicators that were used to rank clinics (“in order to prevent ‘teaching to the test’” IPA et al 2015, p. 8.). Health workers had to decide for themselves what changes to make to improve their clinic’s ranking and have a chance to win the award.
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From the implementing CSOs’ perspective, the NFA method was the least labour intensive intervention. The implementing agency staff were expected to visit the target clinics three times and to hold a short meeting with the healthcare worker in charge.
During the first meeting, the CSO facilitator disclosed the relative ranking of each clinic in comparison with 24 other clinics in the district. The facilitators would then encourage the healthcare staff to identify the problems they faced regarding the delivery of quality health services, and suggest that health workers produce a list of possible solutions they may be able to implement themselves (without external funding). The health workers were asked to draw up a plan of changes they envisaged implementing in the next six months in order to improve the health of the clinic’s catchment community. The health workers were told that all participating clinics would be evaluated after 6-9 months and that there would be an awards ceremony at the end, during which a non-financial award would be given to all clinic staff, and the best performing and most improved clinics would then be announced.
Clinics were revisited three times throughout the course of the nine months’ competition in order to sustain the health workers’ interest. At the end of the nine months, an audit of reported clinic results was conducted: any clinic found to be misrepresenting information was disqualified (IPA et al 2015, p. 8). The gathering of data to determine the ranking of the clinics should not be considered an ‘info out’ component, as the information was gathered by an external agency and was not disclosed to citizens in an attempt to redress information imbalances.
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6.3 Assessing the Non-Financial Awards intervention
This section provides an examination of the implementation of the Non-Financial
Awards method. This section starts by presenting the findings from the health worker interviews and the focus group discussions. This is followed by some additional remarks about the intervention, based on my observations and interviews with key informants and staff from the implementing agencies.
6.3.1 Impact – from the health workers’ perspective
The interview data shows that every health worker in charge of a clinic where the NFA intervention had taken place was able to recall the basics of the project. One health worker revealed that the clinic she headed was ranked number 5 out of the 25 target clinics in Tonkolili District. All the interviewees were clear about the objectives of the competition; the general assumption was that the clinics were ranked according to the best performance in relation to vaccination coverage, facility births and the general health status of the catchment population. In order to win the competition, health workers explained, they were asked to devise their own action plan in order to improve all of the above.
The most popular action undertaken by health workers in response to the competition was to conduct health talks during the days women came for ante-natal care (usually one fixed day per week). Five out of six of the health workers I interviewed reported starting such talks, discussing malaria prevention, hygiene, and the importance of attending the clinic for ante natal care and giving birth. In addition to the health talks, one health worker reported cooking healthy food for the mothers who came to ante-
193 natal care visit to encourage them to come for check-ups, and to demonstrate healthy eating options. She used part of the 40% of the performance based finance (PBF) payments (which is intended for the clinic’s upkeep and incidentals) to pay for the food.
Another health worker bought washable nappies and a safety pin for all the women who delivered their babies in the clinic, to entice them to come to the clinic as soon as they felt the baby was due. In order to try and prevent common diseases, another health worker explained that she had called all the TBAs together and encouraged them to check on the water sources in their localities. Several were fenced off after her intervention, ensuring livestock could not get close to the well or pump, preventing contamination from animal faeces.
Four out of six of the health workers I interviewed started to carry out more regular outreach visits as a result of the NFA competition. Outreach visits are expected to be conducted by all health workers to ensure that the vaccinations of children from the furthest outlying communities within their catchment area are kept up to date. These communities can be as far as 10-15 km away. In all four clinics where outreach visits were conducted with greater frequency, the clinic had no form of transport to facilitate reaching these communities; three of the health workers reported walking to the villages while one explained she used a motorbike taxi and paid for this with the PBF funds. In one case, the health worker (HW54) admitted that she had not carried out any outreach visits in the first year of her assignment to the clinic where she was interviewed, explaining that the obstacles just seemed too great:
When I first arrived I did not do any outreach. I know the previous nurse did, but the fridge was broken and all vaccinations are stored in Magburaka, so it is difficult. When the Non-Financial Awards people came, I decided that I should really start doing outreach, so now I go twice a month. I use PBF money to pay for an okada 194
[motorbike taxi] to go to Magburaka where I collect the vaccines and then I visit the catchment villages. I do vaccinations here at the clinic once a month.
Other actions reported were the purchase of a new blood pressure measuring kit and the increase of vaccination days at the clinic itself. One nurse explained how she tried to tackle the high incidence of sexually transmitted infections by visiting the husbands of pregnant women who repeatedly sought treatment, urging them to be more careful, explaining that infections can cause miscarriages.
My interviews included a question about the charging for free healthcare and free medicine, and all six health workers assured me that such things do not happen in their clinics. Two health workers explained that the issue was discussed at their monthly meetings at the district health administration offices. A third health worker explained to me that patients from a nearby clinic’s catchment area visit the clinic she runs because they allege that “the nurse there asks for money.” It was hard to verify the accuracy of this accusation.49
A question that was discussed in some detail in the NFA health worker interviews was the relationship the health workers had with the Facility Management Committee
(FMC) of their clinic. FMCs were supposed to provide community-based oversight and support for clinics. I had expected that some health workers would have described to what extent they had involved the FMC in their efforts to win the award but
49 In this interview especially, many other indicators pointed to the fact that this may not have been the full story: Our subsequent discussion about what the health worker could do to handle this problem quickly skipped from ‘alerting the village head man of the clinic in question’ (headman of the village where the clinic in question is located) to the assertion that having more medicines could also help to solve the problem. This, coming from a health worker who ran a clinic with inexplicably empty medicine cupboards, only five weeks after a three-month delivery of medicine had taken place, appeared suspicious to say the least. It was the second reference the health worker made to her need for additional medicine. The health worker also explained that the head nurse of the district health authorities had visited the previous day but she had “forgotten” to tell her that she had completely run out of all medication. Finding a clinic apparently without malaria medicine or testing kits was rare, as these were liberally distributed to all clinics for free by several INGOs, and were not found to be out of stock in any other clinic in the entire research sample. 195 interestingly, this response did not come up. When prompted, most health workers agreed that an FMC did exist, and in most cases its members were called in to witness the delivery of the free healthcare medicine, but otherwise the FMCs did not seem to have played a role at the clinics. One health worker (HW40) explained that the clinic’s vaccinator was also an FMC member. In another clinic, one of the TBAs who worked in the clinic was a member of the FMC (HW47). In a third case, the clinic was situated in one of a row of teachers’ houses on the compound of a large primary and secondary school. The health worker in charge (HW71) explained that her two neighbours, two teachers who worked at the school, were the chair and deputy chair of the clinic’s
FMC. The other three health workers mentioned that they had a cordial relationship with their FMCs, though in most cases it was evident that little actual oversight was carried out by members of the FMCs.
6.3.2 Impact – from the health service users’ perspective
This section presents the findings of the focus group discussions that were carried out at six locations close to clinics were the NFA intervention was carried out. The illustration below shows that during the focus group discussions in the area where the
NFA intervention was implemented, five out of the six groups complained about the charges they faced. During the sixth focus group discussion it was difficult to establish how the discussants really felt about the healthcare they received. The women spent a lot of time whispering to each other at the beginning of the discussion and two
196 participants said nothing other than ‘I agree with the others’. Due to time constraints it was impossible to repeat this focus group with a different set of participants.50
Figure 7: Illustration of incidence of alleged charging for free care, raised during FGDs
10 9 8 7 6 5
4 3 No charges for free care 2
clinic 1 mentioned 0 Problem with charges for free care discussed Number of FGDs aboutnearby
When I asked each of the FGDs, it transpired that not a single group of women had heard of the NFA intervention and none could name any improvements that had taken place. This is surprising in terms of changes the health workers claimed to have made regarding increased vaccination days, cooking demonstrations for pregnant women and free nappies for those women who delivered at the clinic. It made me wonder for how long the health workers who claimed to have carried out these improvements had sustained their efforts. Most focus group discussions were held relatively close to the clinic51 so it is possible that the more frequent outreach activities (which was the most
50 For this reason five out of the six FGDs are marked as ‘charges were discussed’ and one is marked as ‘no charges discussed’, although I wonder if the outcome had been the same if I had had time to visit another catchment community to interview a different group of women who used the same clinic. 51 I often chose the nearest catchment village but tried to avoid conducting focus group discussion within the village/town where the clinic was located, to the chance that a health worker or clinic volunteer might be in earshot, which could influence the response women give (the women’s response), as they may be afraid to criticise the nurse if they know s/he may hear ‘who said what’ (if a clinic staff/volunteer could hear the discussion). 197 common improvement reported by the health workers) went unnoticed by women who lived within five kilometres from the clinic.
The focus group discussions in the NFA cluster were dominated by discussions about payments for free care. The women sometimes noted that care had been free when the
FCHI was introduced, but this did not last. One group (FGD41) explained:
Well, initially we were not paying, immediately after the free healthcare came we were not paying, but presently they [the health workers] are asking us for money. […now we pay the following:] For pregnant women, they ask for Le 10,000 [US$2.30] for the ante natal card, for lactating mothers, Le 5,000 [US$1.15]. For maklet [vaccinations], normally they ask for Le 1,000 [US$0.23], because the freezer is broken, the health workers have nowhere to store the vaccines, so they tell us we need to pay for transport for the vaccines. It is Le 1,000 for lactating mothers, and Le 2,000 if a pregnant women needs a vaccination. And for general ante-natal check up, we pay Le 2,000 [US$0.46].
In several cases it seemed as if the health workers initially provided free care and medication after the launch of the free healthcare initiative, but that they reverted to charging several months later either when a new nurse started working at the clinic, or when “free healthcare medication had run out” (FGD41). I tried to clarify how the transition took place:
The nurses say that the government drugs are finished, so now all they have is cost recovery drugs, that is what they are giving us, so we have to pay. […this has been happening] for one year now, it is a year ago that we started paying [FHCI was introduced in April 2010 and this focus group discussion took place in Nov 2013].
When asked why this group thought this change happened, the women were unequivocal: “The new nurse. With the old nurses, we were not paying. But with this new one, the charging started. There's an old nurse and a new nurse now, it must have been the new nurse who came with the idea” (FGD41).
During one of the focus group discussions (FGD48), it became clear that the women who participated were afraid to reveal the charges. Initially the women maintained that 198 the treatment and medication were all free, until a young woman belatedly joined the group just as the question was asked “how much do you pay for your ante-natal card?”
She blurted out her answer without noticing the other women’s hesitation. After this happened, several other women appeared to feel emboldened by the woman’s confession and they also started to talk about the fees they paid for the treatment of those who were entitled to free care. A disagreement then erupted in Temne, which is only translated after the focus group discussion. When the audio is played back, the translator explained that one woman shouted at the others (FGD48):
Don’t talk bad about the nurse, if she hears about this, she will take us to the chief. I am leaving, I am just looking around to see who heard this. If the nurse finds out, I will know who has betrayed me.
The disagreement led to a number of women walking away from the group, but a few stayed and finished the conversation. This was one of the few times that ‘the chief’ was mentioned during a focus group discussion. It was clear from this remark that the patients assumed that the village chief would side with the health worker and not with the patients who complained about being charged for free care. It is therefore not surprising that the participants of this focus group were reluctant to speak out. A close and uncritical (or even colluding) relationship between the health worker and the chief can further exacerbate the power imbalance between the health worker and the healthcare users at local level.
Remarks made during a different focus group discussion (FGD68) shows that women’s reluctance to challenge health workers can stem for multiple considerations, a mixture of understanding a health workers need to earn a living and a very rational awareness of her power to withdraw care:
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[…] if you have your vaccination card, it is free. If the medicine you need is not available, you have to pay. Sometimes the nurse might have the medicine, but sometimes you get a prescription and you buy it elsewhere. […] it is not fair, they call it ‘free medical’, but it is not free. We have no choice, if you have a sick child or are pregnant, you just have to pay. […] We are afraid to challenge her [the health worker]. We would never say anything. She is doing her work and she gets her daily bread this way. If you challenge her, maybe next time she won't give your child good treatment.
It shows that the women were often resigned to the fact that some charging occurred, even if they knew the service should be free. The response to this was often two-fold: in cases when charges were high, women were resigned but resentful, and limited their clinic visits to a minimum. When charges were judged reasonable (often defined as a reduced overall expenditure compared to ‘before the free healthcare’) the women sometimes admitted they appreciated that the healthcare workers charged to earn a living.
Similar to the CM focus group discussions conducted for this dissertation, the overarching themes of the NFA focus group discussions were i) persistent charging for free healthcare and ii) the fear surrounding those who spoke out about these charges.
I conducted one focus group discussion during which the women roundly denied that any charges were levied, but a number of men who had eavesdropped on the conversation cornered the research team’s driver to explain that the women were unable to reveal the charges they paid because of the TBA who was hovering nearby.
The men explained that they were resentful that their wives had to hand over the family’s hard-earned money to obtain free healthcare, and pleaded with the driver to
“tell the white woman the truth” (FGD44). After completing this focus group discussion and having been told about the men’s interjection, I decided to proceed to the following village which was still within the catchment area. A focus group
200 discussion conducted there revealed widespread allegations of charging for free care by the health workers.
6.3.3 The Non-Financial Awards’ implementation challenges
On a practical level, there were no significant challenges encountered during the implementation of the NFA intervention. The four agencies contracted by Concern divided the implementation between them, so in total the four agencies made three
NFA visits to each of the 25 target clinics in Tonkolili.
It was striking to find that none of the key informants I interviewed about the NFA intervention was convinced that this methodology could work, without actually knowing what the evaluations would reveal. During short, informal conversations at the Concern office, it was clear that the team that had been involved in the implementation of both interventions did not feel the NFA programme had yielded any benefits. This may have been because of the experience that they had had with the programme, but it also suggested a bias against non-financial incentives. Even a
Concern driver who took me to the clinics to conduct the research scoffed at the idea of NFA: “Here in Sierra Leone the people want money. They will not try hard if they know they get nothing.”52
The director (KI75) of one of the implementing CSOs made some interesting observations explaining why he felt the community monitoring intervention had been more successful than the NFA project:
We implemented both programmes, but when you look at the two approaches, community monitoring is better, because it doesn't just deal with one individual, like
52 Conversation with Concern driver, Magburaka, 19 November 2013. 201
with Non-Financial Awards. Community Monitoring deals with both beneficiaries and service providers to look at the existing problems of health service delivery and we seek solutions, collectively […]. But with Non-Financial Awards, you merely work with clinic staff, you only deal with the nurse, the nurse makes action plans alone and she works on them alone […]. The difficulty is, she has to do it alone, without community involvement.
He made these comments without actually knowing which of the interventions had been more successful, as the community-based household survey data gathering was carried out by a separate agency, and this data was not released to the participating agencies until long after the implementation was finished. When this interview took place, the data gathering agency had only just completed its data collection.
OPARDS’s director (KI65) went on to provide examples of the types of actions communities undertook as part of the CM compacts: in one location the community constructed benches and shades for women to use as a waiting area, whereas in other places fences were constructed to keep animals from straying into the clinic. He added:
“[These problems] were identified by community and nurses together, so they found a joint solution. During NFA none of this was done, the workload was only on service provider.”
The director of another implementing CSO (KI75) gave a completely different reason for preferring the CM intervention: “I will give you separate scenario of two clinics
[where the two different interventions were implemented]. For one clinic Concern is giving full support for all the activities to monitor the eight [scorecard] indicators, while this [other] clinic is left without any of those incentives […]. So you can see that those that really have all the support […], they get food, they get transport allowance
[…].”
When I checked if he meant that his staff received these benefits, he clarified: “No, for the participants […]. So for NFA, we do not give these kinds of incentives, you go 202 there, you give them the information, you follow them, but you don't see the actual cooperation of the people.”
The views of the COBTRIP director’s seem to reflect the driver’s conviction that without paying people, they will never be interested in doing anything. The CSOs earnt little when they implemented the NFA intervention. In contrast, they earned a lot by implementing the labour intensive CM intervention, which involved visiting dozens of outlying villages while compiling the check lists, or convening the compact meetings. In addition, there was clearly a fondness for paying per diems, which was often not only related to the programme participants’ benefits, it is also linked with the common practice of ‘skimming allowances’: if participants are not aware of how much money has been allocated per person, it is easy for the person who distributes the cash to keep a small percentage of the participants’ allowances for him/herself (Bullen
2014, Vian 2011).
6.3.4 Implementing CSOs’ shortcomings
When the project method was discussed with the health workers, some mentioned repeated visits, but not one, out of six health workers, mentioned that he or she had received three visits. In some cases it appeared that the CSO facilitators had been visited only once. Given that health workers leave the clinic to go on outreach visits to vaccinate children in remote communities, and usually travel to the district capital once a month to hand in their report and collect their salaries, it is likely that some visits were conducted at a time when the health workers were absent. However, the NFA guidelines for all CSO staff stated that they should repeat their visits until the same health worker(s) was visited three times: it appears as if a general lack of commitment 203 to this intervention may have led to a reduced effort from the CSO staff to complete the ‘three follow up visits’ schedule.
6.4 Analysing the Non-Financial Awards intervention
This section will use the analytical framework to examine the NFA intervention. This chapter’s analysis will draw on the material from the field research that was conducted between 2012 and 2014 (interviews, focus group discussions and grey literature), as well as on a series of interviews with and publications by World Bank and IPA staff who were involved in the design or in the implementation of the Randomised
Controlled Trail that the Non-Financial Awards intervention was part of.53
6.4.1 Redressing information imbalances
There is only one small information component in the NFA methodology: it is the disclosure (to the health workers) of the relative ranking of their clinic in comparison to the 24 other clinics which were also selected for the competition. The competition and the ranking seem to have been the key motivating factor that spurred on the six health workers I interviewed about the NFA intervention. All six explained how they made certain changes to improve their work practice. Given that the health workers were told that the award they could win was non-monetary, it can be presumed that their professional pride encouraged some health workers to change their behaviour.
53 These texts include interviews with Nicolas Menzies (in Freetown, Sierra Leone on 20 May, 2014 and in Washington DC on 14 May 2015) of the World Bank, and with staff members of the agency Innovations for Poverty Action (IPA), who jointly published the following papers, articles and case studies: Grandvoinnet et al 2015, Hall et al 2014, Hall 2012, 2013, IPA 2015a, 2015b, IPA et al 2015. 204
This finding is clearly contrary to the expectation of the implementing agencies, but it is similar to behaviours documented in other social experiments in low-income settings
(Kosfeld and Neckermann 2011). Not only that, but it appears that the changes in behaviour, however small, were fairly well sustained, given the fact that few clinics received the required three visits and that health workers generally reported not knowing when they would find out if they had won the competition. In most cases the health workers had continued with the improved practices they had introduced as a result of the NFA intervention.
As mentioned in the intervention’s description, the data gathering for the ranking, which was done by an external agency, should not be considered an ‘info out’ component, as the survey participants were not made aware of the survey’s connection to the NFA intervention and the data gathered was not fed back to the community in the target clinics’ catchment villages.
While the designers of this intervention had good arguments for the deliberate non- disclosure of the scorings criteria (to avoid clinic staff focusing all their efforts on
‘winning’ behaviour changes) one cannot help but wonder how the intervention would have played out if clear scoring criteria had been disclosed. After all, nobody could have faulted a health worker for ‘teaching to the test’ behaviour if that meant s/he made concerted efforts to ensure that all children in the catchment community were fully vaccinated or if s/he enticed increasing numbers of pregnant women into delivering their babies at the clinic. Had the designers of the intervention thought about this more carefully, they may have concluded that revealing the indicators used to score the clinics could only have led to more targeted behaviour changes, which would have been a desirable outcome. For example, disclosing the fact that a question about
205 charges for free healthcare was included in the patient questionnaire that contributed to the scoring of the clinics, could have had a reductive impact on such practice.
6.4.2 Citizen participation
This intervention was deliberately designed without any citizen engagement component, to test the necessity of bottom-up pressure to motivate health workers to improve their performance (Hall et al 2014, p. 10, IPA et al 2015, p. 7), or, alternatively, whether a top-down method, such as the NFA intervention, would be as effective as well as cheaper to implement.
6.4.3 Power and political awareness
The nature of this intervention, which was targeted solely at health workers, with no additional linkages to other individuals, be it the community, the facility management team or the district health authorities, provided a unique test of the health workers’ behaviour, as it was conducted without engaging the district health authorities or altering the health worker-community relationship.
It appears that all the health workers who were included in this research’s sample responded to some extent to the NFA competition. During interviews, each health worker was able to outline a number of improvements that s/he had made to her work practice in order to win the award. However, given the fact that no direction was given as to what could amount to winning behaviour, and that no pressure to change was exerted by the community, the district health authorities, the FMC or anybody else, it
206 was clear that it was completely up to the health workers to decide what behaviour changes might suit them.
Evidence suggests that the health workers made careful calculations as to how much effort they wanted to invest in trying to win the NFA competition. It was clear that reducing their charges for free healthcare was not opted for as a type of behaviour change by any of the health workers included in the six-clinic sample that this research focused on. The data from the entire sample of 85 clinics (in three districts) in which the NFA intervention was implemented, recorded no reductions in illegal fee charging
(IPA et al 2015, p. 12). This outcome is somewhat surprising, given the fact that when health workers know their clinic is being entered into a competition, they might have been worried that their illegal charging would be discovered. It appears as if the complete lack of change when it comes to charging behaviour might be due to the fact that the health workers were unaware that charging for free care was being monitored, and they therefore felt at liberty to continue doing so. This almost brazen behaviour seems to reflect the realities in which health workers in rural areas operate: existing monitoring by health authority supervision teams is infrequent and often focused on the clinics that are closest to the district headquarter town (where the DHMT offices are), which has led to many health workers operating in a near ‘accountability vacuum’ when to comes to charges.
It was evident that those who should have kept informal charges in check were neglecting to properly investigate if such charges were levied. District health authority staff who were responsible for stamping out improper conduct at rural clinics were often aware that charging for free care was common. They usually accepted it as a
207 necessary means of survival for health workers who operated in structurally unworkable circumstances.54
The notion of health workers in rural clinics working in a largely unsupervised environment is further confirmed by the responses to the question about the Facility
Management Committees. The research findings showed that half of the health workers reported that the Facility Management Committees included either a volunteer member of staff or a close neighbour. In neither of those cases did it appear likely that the FMC would have been able to act as an unbiased group of individuals who could hold the healthcare staff accountable for delivering quality healthcare.
Patients who suffered the charges were unable or unwilling to speak out. Interestingly, the most vocal criticism of a team of health workers’ charging in this group of clinics, came from the husbands of women who were regularly charged for care when attending their local health facility. This in itself speaks volumes; the men clearly felt able to voice their disapproval because they were less intimidated by the health workers. However, as it was usually the women who attended the clinic with their children, the men’s willingness to criticize the health workers may also have stemmed from the fact that they would not have been the ones facing any consequences if the health worker learnt about their complaints.
6.4.4 Staff motivation
The NFA intervention demonstrated clearly that it was possible to motivate health workers to change their behaviour in a challenging operational environment. While the
54 This knowledge was alluded to by several members of Kono District Council (KI94), and the large majority of key informants I interviewed in Freetown, May 2014. 208 changes were limited, they nevertheless had an impact on the communities that benefited from the increased outreach visits, on the women who received additional health talks or cooking demonstrations, or who decided to give birth in the clinic where the health worker offered free nappies. This fact was completely missed in the reports that evaluated the success of the randomised controlled trail. It is striking how the two different methods of data gathering (quantitative community-only data by IPA and the qualitative research carried out for this thesis) came to different conclusions about this intervention. While the one-to-one interviews with health workers for this research captured the efforts the health workers made to win the award (primarily reflected in additional outreach visits) the quantitative measurements and a limited amount of household surveys that IPA carried out, found only inexplicably higher levels of nurse absenteeism within the NFA sample (IPA et al 2015, p. 12).
Had the design of this intervention been more carefully thought-through, if it had closer links to, for example, the District Health Management Team and the Facility
Management Committees, and if the awards ceremony had followed on swiftly after the intervention period with possible media coverage and a small ceremony at the winning clinic, this method may have yielded better results and it may have been recognised as a low cost approach to improving staff motivation and to changing certain types of health worker behaviour.
Interestingly, none of the health workers chose to reduce the charges they levied for free care. Seemingly, many health workers thought that nobody noticed their illicit charging, even when their clinic was entered into a competition. This is perhaps not as strange as it seems, health workers had been getting away with charging for free care for several years: they were well aware of their power over the communities and know
209 that many patients would be reluctant to reveal that they ‘pay for free health services’.
Secondly, the charging that went on was often ‘out of necessity’. Health worker’s professional life would have been much more difficult if no charges were levied, so it is not a practice that is given up easily.
As explained in chapter four, after the introduction of the FHCI, staff55 who were not on the newly cleansed payroll were simply assumed (by the authorities and donors supporting the FHCI) to have continued working in a voluntary capacity without pay or to have stopped working altogether. The reality on the ground was very different: directly after the FHCI introduction, 30% of all the rural clinics continued to be staffed by a single health worker who could not run a health facility alone, day and night, all year round. So in actual fact, many clinics carried on working with a series of unpaid
‘volunteers’, including traditional birth attendants, who have often joined clinic staff for the first time after the introduction of the FHCI, as the government pressure to stop home deliveries increased. Many health workers therefore continued charging for free care when it was introduced, because they could not maintain the ‘unpaid’ staff who were vital to the running of the clinic. Meanwhile health workers complained about being unable to generate an income for the staff who were not on the payroll, which appears to have been tacit admissions that they were under pressure to provide such funds. One can only assume that this impossible situation was very demotivating for healthcare staff, who were forced to choose between running a clinic singlehandedly - and therefore being unable to provide the right level of care - or charging, and hereby undermining people’s access to care.
55 I loosely refer to everybody who ‘worked’ at a health facility before the FHCI as ‘staff’, even though many individuals who were found at clinics before April 2010 were not appointed by anybody, and many had no qualifications to work there (Amnesty International 2009). Some did have qualifications (often because they received training abroad while they were refugees during the war) and others were appointed shortly after the war ended although they were never put on the government payroll. 210
I believe that the service improvements that were achieved by the NFA intervention demonstrate that if the district health authorities provided the necessary ‘supportive supervision’, the quality of healthcare that was being provided could have improved dramatically. If the right questions had been asked during routine DHMT supervisory visits, it would have revealed that many health workers neglected to go on outreach visits to neighbouring communities, and, one would hope, corrective actions could have been taken.
One of the conclusions that can be drawn from this intervention is the fact that health workers responded to the motivational trigger of a competition. The competition, which was judged through an external monitoring system used a top-down approach, did not involve the community in any way, and thus there was no ‘bottom up’ pressure to speak of. This means that technically, the NFA method was less of a ‘social accountability intervention’ and more an ‘accountability intervention’. However, the definition of social accountability is broad and the inclusion of the Non-Financial
Awards intervention provides an interesting opportunity to compare this method with the other social accountability approaches examined in chapters five, seven and eight.
For this reason, I believe it is important to consider this method.
6.5 The findings from the ‘control’ interviews and case studies
This ‘addendum’ to chapter six presents the findings of the research I conducted at six control clinics, i.e. clinics where no social accountability intervention took place. As discussed earlier on in this thesis, the Community Monitoring and the Non-Financial
Awards interventions were part of a Randomised Controlled Trial (RCT) that was
211 conducted in three districts in Sierra Leone. The RCT included a control study, which meant that the data gathering agency IPA did not only focus on the clinics where one of the two interventions has taken place, it also collected community-wide health statistics in an equal number of catchment communities of ‘control’ clinics where no intervention had occurred (IPA et al 2015, p 9). As a precondition for gaining access to the CM and NFTA clinics, I was also required to conduct research at a similar number of control clinics.56 The results of these health worker interviews and focus group discussions conducted in the six ‘control’ study locations, are the focus of this short addendum. This part of the field research was carried out in Tonkolili District, it therefore seemed appropriate to present it as a part of chapter 6, hereby concluding the
Tonkolili-focused section of the case studies.
Because there was no social accountability intervention to focus on, as such, the interviews and focus group discussions primarily revolved around the challenges of healthcare delivery in the context of the recently introduced Free Healthcare Initiative.
6.5.1.1 Impact – from the health workers’ perspective
For the ‘health worker in charge’ interviews, the focus was primarily on how they experienced their jobs. Among the six (all female) health workers who were included in this sample, two had recently graduated and were still considered as trainees. They were both the only skilled employees in their clinic, and fulfilled the role of ‘in- charge’. Neither of these health workers were on the government payroll and therefore received no salary and did not expect to be reimbursed. When asked how they coped
56 In order to obtain permission to conduct research at the clinics where the RCT took place, I had to obtain permission from the World Bank, from the data gathering agency IPA and finally from the implementing agency Concern. 212 without pay, one health worker explained how she found it “difficult but I manage”
(HW37) and seemed to really be surviving on handouts from the community. The other ‘trainee’ health worker was more circumspect about how she managed her affairs, and during the focus group discussion with healthcare users in her area, the health worker was accused of charging for free care – which is not entirely surprising, given the circumstances.
The discussion about surviving without a salary did cast an interesting light on how health workers generally survived and what coping strategies were employed. One unpaid health worker highlighted the importance of workshops: “even workshops […] it is very difficult for me to attend workshops because I don’t have network [mobile phone coverage] here, so I can’t get called for workshops. What I could gain from workshops would help me manage my own life, but no workshop, no per diem […]”
(HW66).
The conversations with all of the health workers revolved around the changes since the introduction of the free healthcare. They all agreed that it has brought an increase in workload. One explained: “At first, when we were here, when there was no free healthcare we could see 100 patients per month, sometimes 80, sometimes 120, but now, since the free healthcare, we get 200, sometimes even up to 300!” (HW58). How heavy the workload is, depends on one’s interpretation. In one clinic where two health workers were employed (and on payroll) the health worker in charge explained:
“When the workload is heavy we share the work, we work at the same time, usually on immunisation day. Otherwise we swap, I work one day, she works the other day. We have immunisation day twice per month” (HW34).
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The same two health workers explained that three unpaid volunteers worked at the clinic: a vaccinator, a TBA and a cleaner. It is unusual to have only one TBA in a small clinic, but when I asked, the health worker explained that there were only two
TBAs in the community, but "the other one is just relaxed because she says she is not paid" (HW34). I assume that having two paid staff at a not so busy clinic makes health workers less reliant on the assistance of TBAs, and more reluctant to pay them what they demand, hence the decision of one of the TBAs to not continue working at the clinic.
6.5.1.2 Impact – from the health service users’ perspective
The focus group discussions, like the health worker interviews, did not have any specific intervention to talk about; instead the discussions therefore focused on the health services the women received in general. Comparing the situation before and after the free healthcare initiative was a starting point for the debates.
As illustrated below, there was only one focus group discussion during which no allegations were made of charging for free healthcare. Surprisingly, the clinic where no charges appeared to have been levied was the clinic which was staffed by a single health worker who had just qualified and was not yet on payroll. The health worker appeared to have had strong support from the community, including the Facility
Management Committee (the FMC chair lady popped by unannounced during the interview), which may have contributed to the establishment of a support system for the health worker which was based on donations in kind rather than demands for payment.
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Figure 8: Illustration of incidence of alleged charging for free care, raised during FGDs
10 9 8 7 6 5
4 3 No charges for free care 2
clinic 1 mentioned 0 Problem with charges for free care discussed Number of FGDs aboutnearby
The focus group discussions conducted in the control clinics provided interesting insights to what many of the rural clinics in Sierra Leone must have been like at the time of the research. The discussions pointed towards considerable accountability challenges.
The sample included three focus group discussions during which the majority of the women openly admitted giving birth at home rather than at the clinics. Since the introduction of the FHCI, there has been a lot of emphasis on trying to persuade women to give birth at health facilities where they can access skilled assistance. While the initiative was a success, and facility birth rates reached 54% by the end of 2010, the year free healthcare was introduced (Sierra Leone Ministry of Health and
Sanitation 2012), by 2013, the rate had only increased to 54.4% and great inequalities continued to exist between the number of urban women who deliver their babies with
215 the assistance of a skilled attendant (78.9%), versus 53.2% of rural women who do the same (Sierra Leone Demographic and Health Survey 2013)57.
It was noted that most communities now have by-laws against giving birth at home, some apparently dating back to before the FHCI (Herschderfer et al 2012). Nobody is entirely certain what percentage of women decide to opt for a delivery at the clinic because of the by-laws – such decisions are usually based on a range of factors, including cost (both of the delivery and of the possible fine), but also trust in the healthcare staff and distance to the clinic (Bohren et al 2014, Treacy and Sagbakken
2015). Due to repeated efforts by government and NGOs to promote facility deliveries, giving birth at home was known to increase the risk of maternal death, and the narrative I heard in rural Sierra Leone implied that homebirths rarely happened anymore. It was therefore striking to encounter three groups within the small sample (3 out of 6) of focus group discussions in which home deliveries were still the norm.
In one focus group, the women made it clear that the charges levied at the health centre influenced their decision to have their babies at home (FGD 36). When asked why all of the women had given birth at home, the women admitted:
Yes, all [twelve babies here] were born at home. The money is a problem, that’s why they don't give birth at the PHU. They normally demand for soap, wrapper, money. They ask you to bring soap, you bring cloth to wrap the babies, and money. [The nurse charges] Le 40,000 [US$9.20] for a boy […] and Le 50,000 [US$11.50] for a girl. […] a girl baby is more expensive because they say a family will be happy to come and marry the girl, the parents will get a bride price, that's why.
57 Rural facility delivery rates vary enormously, the 2013 SL DHS states: Just over half (54%) of deliveries occur in health facilities, primarily in public sector facilities. Facility based births are least common in Kambia (34%) and Koinadugu (33%) and most common in Kailahun (84%). More than 2 in 5 births occur at home. Home births are more common in rural areas (49%) than urban areas (30%). Facility-based deliveries have more than doubled since 2008 (2013, p. 8). 216
In the second focus group where the same appears to be happening, the women were less open about charges at the clinic. Seven out of the eight small babies on the laps of the focus group discussants were born at home, but the women maintained that delivering a baby at the clinic was free. It later turned out that the TBA, who lived in the village and maintained strong connections with the clinic, was sitting nearby. A short section of the transcript shows how the women were divided about how honest they should be during the discussion (FGD45). When asked if charging occurred, the women were silent for a while, after which some admitted:
Yes, they take money from us. We don't pay for drugs, but we give them gesture, to pay for nurse's transport, when they come for outreach. When we go to clinic, we don't pay.
Others disagree, but after some discussion, one women states with some authority:
“We pay Le 5,000 [US$1.15] for the ante-natal card and for the baby’s vaccination card we pay Le 4,000 [US$0.92]”. When I asked the women subsequent questions about how much they were charged when their children are sick or needed a malaria test, the conversation in Temne became hard to control. After a while, my translator explained: “They are discussing, some are in favour […] others are against.” When I enquired if she meant the women were debating whether or not they were against the charges, it turned out that I was wrong. “No”, said my translator, “they are debating whether they should tell you about it or not.”
During the third focus group discussion in which an unusual amount of women admitted to giving birth at home, the women explain that yes, there are by-laws against giving birth at home without the assistance of the TBA, but if the TBA is present, they will not receive a fine (FGD64).58 This seems to be completely contrary to government
58 In this case, 4 out of the 9 babies present were born at home. 217 and FHCI policy, but again, it was not the first time that the research uncovered liberal interpretations of the guidelines that are supposed to steer public healthcare practice.
Overall, levels of knowledge about the free care were adequate, but the women reported not feeling empowered to challenge the nurse and ask for free care. “Nobody dares to ask why we have to give money […] you need the welfare of your child, so you don't even ask”, admitted a woman in one discussion (FGD64). The same group of women admitted to being afraid to tell either the FMC members about the charges, while another group explained that they would never complain to the DHMT representatives about the nurse, because they would be afraid of retaliation. Several women in one group did recall complaining to somebody from the DHMT, but all he did was note their complaints and nothing happened (FGD 67).
It seemed as if different levels of charges were set by different health workers, to which patients responded by choosing to access alternative options if the costs were too high. In contrast to the three clinics at which very few facility births took place, there was one focus group in which all discussants reported delivering their babies at the local clinic (FGD59). The clinic in question had a clear and transparent fee system in place, which was based on paying for the ante-natal or vaccination card and receiving all further ante-natal care and vaccinations for free, plus a set 2,000 Leone
[US$0.46] treatment fee for when a child was sick. The women saw this as a huge improvement on the ‘pre-free healthcare system’ and were happy to pay what they considered acceptable charges:
Of course we want free healthcare […] but nurse also has to survive, she needs the soap. We are happy that she will treat you if you don't have money, so we don't mind the 2,000 that we are giving her now and then.
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6.5.2 Analysing the control cases
This section will provide a brief analysis of the findings of the control cases, using the analytical framework that is applied throughout this thesis for the analysis of each of the four ‘treatment’ case studies. This provides the opportunity to compare the ‘control clinics’, in which no intervention took place, with the clinics at which one of the four accountability interventions was implemented.
6.5.2.1 Redressing information imbalance
In terms of access to information, it appears that the participants of the ‘control’ focus groups had a reasonable amount of knowledge about the free healthcare. In four out of six of the control clinics where I conducted a focus group, the women complained about charging, and in each case the women demonstrated that they knew which categories of patients should be entitled to free care. In several cases the women mentioned their ‘payment for free care’ history, recounting how the care and medicine had been free for the first few months after the FHCI was launched, while another group said that the previous nurse charged much less than the current one, again tracing the quality of care and paying for care history back to 2010 when the FHCI was introduced. This shows that the information campaigns conducted in this area had worked reasonably well.
Despite the fact that all the women had a good basic level of knowledge about free care entitlements, there were also clear gaps: almost all of the women reported paying
219 for both ante-natal cards and for their children’s vaccination cards, which are supposed to be free or carry a very small ‘reprinting’ charge.59
In addition, most women reported paying for medicines when the free healthcare drugs had run out. Here too, pregnant and lactating women were aware that they or their children were entitled to free medication, but most reported paying either because the drugs were unavailable or to secure the ‘better’ medicine, such as syrups for children.
During the focus group discussions it was clear that the women had adequate information about the free healthcare and were technically able to challenge the health workers about the fact that they did not receive what they are entitled to. However, in practice, this simply did not happen; the women were reluctant to challenge the nurse because she could withhold treatment when they most needed it.
6.5.2.2 Citizen participation
As highlighted in the health worker interview section, I encountered only one FMC that actively supported the clinic and the unpaid health worker who was recently assigned to the facility. This particular group was led by a dynamic woman who clearly had the leadership capacity to rally around the health facility to ensure that its unpaid staff member did not absent herself and leave the clinic without a trained health worker in charge. In the other five cases the situation was far from similar: there was only one focus group discussion in which the FMC was mentioned unprompted, and this was in the context of a complaint about their lack of engagement with the clinic:
59 The FHCI is so unclear that even among key informant interviews with the Ministry of Health staff it was impossible to receive a conclusive answer: the predominant view was that these cards should be free and if a charge is imposed, it is because of re-printing costs, if they run out (though it was pointed out that the PBF funds can be used to pay for reprinting). 220
“The committee is not working, they are not trying to solve the problems, they are just dormant - even the committee members and their wives have to pay for their healthcare” (HW67).
It was clear from the interviews and focus group data that despite the official existence of the FMCs, the majority were no longer operational in such a way that they could provide communities with access to a mechanism that would allow them to participate in clinic-related decision making. With a complete lack of FMC engagement, a community’s first line of recourse against maltreatment by a health worker was effectively taken away.
Whether or not FMCs would ever be suited to carry out clinic oversight duties is another question. Existing power imbalances are difficult to address by individuals who rely on the same health workers when they or their family members are ill. The way in which the FMCs were established may have further contributed to their lack of efficacy, of recognition within the community and of their own sense of duty. The decision to establish this accountability mechanism came eighteen months after the introduction of the free healthcare initiative, and appears to have been in response to donor pressure created by the many corruption cases uncovered by the media after the introduction of the free healthcare.
6.5.2.3 Power and political awareness
The focus group discussions conducted in this cluster of clinics revolved predominantly around the charging for free care. The women I interviewed were aware of their entitlement to free care (for themselves or for their children), but were resigned to the fact that they were unable to stand up to health workers when they demanded 221 payment. The women in this group had clearly made a rational choice to put up with the financial demands of the health workers because they were afraid of the alternative: being denied treatment.
It was clear that the women felt disempowered and felt unable to trust any of the entities that were in place to protect their interest. When I asked one group of discussants if they had considered complaining to the DHMT staff who they see visiting the clinic regularly they were aghast and wondered out loud “what if that
[DHMT] person would point his finger and tell the nurse: it was her who made the complaint” (FGD36). The focus group discussants were equally distrustful of the
FMCs, whom they saw as ineffective, no longer playing a role, and so powerless themselves that even FMC members paid for healthcare, the women explained. On one occasion, a group of discussants openly expressed their fear of being reported to the chief by the health worker for speaking out against the charges she imposed (FGD48).
The focus group discussants’ “fear of being ‘brought to the chief’ by the health worker, if the women disclosed the illegal charges they were forced to pay” was encountered on one other occasion (FGD55) during this research. While such fears were clearly not overly common, the fact that they were expressed twice within 35 interviews did show that some women in rural areas felt isolated; unable to trust the health worker to provide the care they were entitled to, and unable to trust the chief to protect the interest of ordinary women within his chiefdom against the interest a profiteering health worker. Given how common problems of collusion and backdoor deals are involving local politics and traditional authorities, especially in mining areas such as
Tonkolili (Acemoglu et al 2012, Edwards et al 2014), this expression of
222 disempowerment is likely to have been informed by repeated experiences of being disadvantaged by those in power.
In many cases communities appeared to have felt unable to leverage their collective power to demand their right to free healthcare. Collective action problems prevented many communities from negotiating a reduction in fees, or greater predictability in terms of the charges they faced. There were some communities in which this was possible: the community that reported no charging for free care appeared to have had a significant support structure in place (with gifts of food and fuel) for the new, unpaid nurse in order to dissuade her from leaving her duty station or from starting to charge.
The key to this success appeared to have been a proactive FMC member, who was able to mobilise her community to ensure a regular supply of in-kind support and was able to strike a deal with the health worker. Such interlocutors are crucial when it comes to a rebalancing of power between health workers and the community, but they are not always present in every location. Even when grassroots groups are established through external mechanisms (such as with the FMCs), these individuals are not always selected, as the natural deal maker can easily be overlooked in favour of the literate school teacher or the chief’s wife. This study does not provide the opportunity to examine in greater detail under what circumstances a deal could be struck in favour of the community, though this is an area of study that warrants further investigation.
6.5.2.4 Staff motivation
The interviews with health workers and healthcare users in the control area throw an interesting light on the issue of staff motivation.
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From a health users’ perspective, the six clinics examined for this cluster included one clinic where health users were not charged any user fees, but the community and the health worker admitted that the community provided food and fuel for the unpaid health worker. There was a second clinic where the users paid a modest set fee, which the patients reported as being reasonable. In both clinics the relationship between the health workers and the patients seemed good. Facility birth rates and vaccination coverage was high in both these clinics, which would have led to the opportunity for the health workers to earn a modest premium through the performance based finance programme. At the remaining four clinics the charges levied for free care were reportedly significant, patients reported being scared of the health workers and self- reported home birth rates were very high.
From the health worker‘s perspective, there were several scenarios: out of the six clinics, five were staffed by a single health worker, and two of those were not on the payroll. The two health workers who were not on the payroll dealt with their lack of official income in two completely different ways: one charged for the care she was supposed to give for free, while the other was able to rely on the generosity of the community to survive. While the unpaid health worker who enjoyed a good relationship with the community appeared content and at ease with the patients and neighbours who called during the interview, the other unpaid health worker had no contact with the community, she complained of the loneliness of her post and travelled
20 km each way to visit her family every Sunday, leaving the clinic closed for 24 hours every weekend. One could not help to speculate what positive change (for both health worker and community) a well-functioning FMC could have brought in this case.
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The clinic with two health workers on payroll was an interesting case to examine. The health workers reported that the clinic had been constructed by the NGO Concern and opened in 2010, not long before the introduction of free healthcare. The relatively light workload that appears to be easily shared between two health workers, poses questions around the health workers’ allocations: does this clinic have two paid staff because
Concern demanded that this would be the case (it is a minimum requirement according to WHO standards) as a precondition for their clinic construction intervention?
What is fascinating about this case is the fact that we can speculate about what might have happened to the relationship with the TBAs if there had only been one health worker on payroll: there were very few cases in which a single health worker in charge reported having a conflict with the TBAs in the vicinity – I guess they were simply too dependent on them to fall out.
6.6 Conclusion
The overarching theme of the six focus group discussions carried out in the control area was similar to those conducted in areas where the NFA method had been implemented: persistent charging for free healthcare was alleged in five out of the six cases. The second theme that emerged in the ‘control’ sample was the prevalence of home births, which was higher than in the other samples.
Having conducted an examination of a small number of ‘control’ cases, it was possible to speculate that this was how other rural health facilities in Sierra Leone operated at the time of the study. The control cases provided an opportunity to compare the situation in these six clinics with that in the clinics where the accountability
225 interventions took place. The evidence suggests that the problem of charging for free care was as commonly reported among the focus group discussants in the control group as it was among the NFA group. How the NFA data compared to the other interventions will be examined in greater detail in chapter nine.
The NFA intervention provided this research with invaluable insights into the effectiveness of certain isolated aspects of social accountability interventions (such as the ranking information and the awards competition). While charging for free care appears to have remained common before, during and after the intervention, some health workers nevertheless made improvements to their working practices: several health workers increased the frequency of outreach visits, others started to schedule more frequent ante-natal and vaccination days, and one health worker even started to offer reusable nappies to women who delivered at the clinic, to boost facility birth rates.
One of the most surprising outcomes of the comparison with the research paper that evaluated the RTC (Grandvoinnet et al 2015, Hall et al 2014, IPA et al 2015, IPA
2015b) was the realisation that this research came to quite different conclusions when judging the efficacy of the NFA method. The fact that the data collecting agency failed to identify the efforts healthcare workers had made in order to win the NFA competition, confirms how difficult it is to capture all the information about a particular intervention with any standardised set of data collection tools. Being able to access the findings from the RCT and combining them with the field research conducted for this study, allows me to benefit from the findings generated by both quantitative and qualitative methods.
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Chapter 7 - Case study C: Participatory Monitoring
and Evaluation
7.1 Introduction
This chapter presents the evidence from the examination of case C, the Participatory
Monitoring and Evaluation (PM&E) intervention. This intervention was implemented by the Ghanaian NGO SEND Foundation, which worked as an implementing partner with Christian Aid. The location in which the intervention took place was Kailahun
District. Section 7.2 introduces Kailahun District. Section 7.3 provides details of the
PM&E methodology and elaborates on the implementation of the intervention. Section
7.4 presents the findings from the field work, which took place in Kailahun. This section also draws on SEND’s programme documents, providing insights into the challenges of the operational environment, from staff shortages to the dysfunctionality of the facility management committees. Section 7.5 uses the analytical framework to examine the evidence that was gathered during the field research. Section 7.6 concludes.
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7.2 Setting and historical context: Kailahun District
Kailahun District
is Sierra Leone’s
most eastern
district, bordering
both Liberia and
Guinea. Kailahun
is commonly
known as part of
the Mende
dominated ‘south’
of the country.
Agriculture is the mainstay of the population of Kailahun, which is densely forested. Kailahun produces mainly coffee, cocoa and palm oil as cash crops and rice, maize and cassava for home consumption (UN World Food programme 2011).
Paul Richards, reflecting on colonial times, notes that Kailahun has long been thought of as a ‘difficult’ region:
[…the] ruling families divided into “treaty chiefs,” recognized by the British, and others who rejected British rule. Those who rejected British rule were especially notable in the Liberian border region, and some border chiefs (of Gola and Kissi background) adopted a somewhat migratory life-style between settlements and family segments in two or three countries (British-ruled Sierra Leone, independent Liberia and French-ruled Guinea). For this reason, Kailahun District has retained its reputation as a “difficult” region even to this day, and the Libyan-backed RUF exploited some of the grievances of these “excluded” families. (Richards et al 2004, p. 3)
228
Kailahun is best known as the area of Sierra Leone where the rebel RUF first entered
Sierra Leone (from Liberia) and where they received strong support among civilians.
When the RUF rebels first crossed into Sierra Leone, they did so along some of the traditional diamond smuggling routes. As the section on war narratives has already alluded to, Richards suggests that the RUF found many willing conscripts among the disaffected young men of Kailahun (Richards 2003, p. 12). Sierra Leone sank deeper into economic decline at the end of Siaka Steven’s leadership, and in the early years of
Momoh’s rule, rural schools closed or were forced to impose fees, as the state could no longer pay teacher’s salaries. Momoh made a famous speech in Kailahun in which he stated that education was a privilege, not a right (Richards 1996, p 36). Larizza et al explain that in the decades leading up to the outbreak of the civil war, rural, opposition
SLPP-voting districts, including Kailahun and most of the Mende dominated south and east, suffered particularly badly from the centrally imposed chiefdom structure, which put loyal party members in charge and gave them the opportunity to raise local taxes and impose fines, while providing little in return:
The tendency to confer paramount chieftaincies to party loyalists regardless of their ruling house credentials often generated prolonged local protest and campaigns of civil disobedience (Fanthorpe 2006, Reno 1996). Combined with the overcentralization of power in the hands of a single party (APC) in Freetown, the authoritarian tendencies of the chiefs magnified popular discontent. The governing style marginalized wide sectors of the population and provided a ready opening for youth conscription into the fighting rebel factions when the RUF crossed the border from Liberia, eventually bringing the country to civil war (Hanlon 2005, Humphreys and Weinstein 2008, Richards 1996). (Larizza et al 2014, p. 181)
Despite the alleged enthusiasm in Kailahun for a possible force that could overthrow the APC government, support for the RUF appears to have been mixed. The brutal tactics of Liberian and Burkinabe soldiers who fought alongside the RUF in the early stages of the civil war cost many innocent civilians’ lives in the border region and lost 229 the RUF a lot of support (Richards 2003, p. 11). Throughout the war, the rebels were able to hold on to small territories in northern Kailahun and the Gola forest, but this did not mean the entire population of the district was in support of the rebels’ causes, nor were civilians spared rebel raids, forced child soldier recruitment, or brutalities inflicted upon them by the army or militias (Richards 2003, pp. 12-18).
Kailahun was left devastated by the civil war, ranking second and third poorest district for rural and urban poverty in 2002/3 (Wang 2007, p. 21). The same report ranked
Kailahun as the post-war district with the most severely damaged primary school facilities, with over 80% of the buildings needing major rehabilitation or reconstruction (2007, pp. 68-69).
The war impacted negatively on agricultural output, particularly on cocoa and coffee, which were the most important cash crops for Kailahun households during peace time.
A UN human development report in 2007 noted that most of Kailahun’s tree crop plantations were abandoned for over ten years during the civil war (UNDP 2007).
While a certain amount of post-war reconstruction funds have reached Kailahun over the past fifteen years, the district continues to struggle with significant infrastructural shortcomings, even today. Kailahun’s remoteness has been exacerbated by its continued lack of a tarmac road from the capital Freetown to its district capital
Kailahun Town. Most basic service indicators remain lower in Kailahun than in other parts of Sierra Leone. Christian Aid/SEND’s programme documents cite key statistics from the 2008 Demographic and Health Survey: “[Kailahun District has a] female literacy rate of just 22%, under five mortality in 2008 was 189 against the national target of 90 per 1,000 live births and infant mortality 112 against the national target average of 50 per 1,000 live births. The Kailahun population, in particular women and
230 children, suffer from high levels of malaria, pneumonia and diarrhoea […] caused primarily by limited access to quality health services (Christian Aid 2010, p. 8).
The same report also noted:
In Kailahun, Eastern Province, the poorest district in the country, where 74 PHUs and 2 referral hospitals share just 3 medical doctors between them and serve a district population of approximately 358,000 people across 14 chiefdoms, less than 32% of children were delivered by a skilled birth attendant in 2008 and just 0.4% of all births delivered by caesarean section. (Christian Aid 2010, p. 9)
By 2011, Kailahun’s poverty rate had come down to 60.9% (from an average rate of
86% in 2003 for the whole Eastern Region, Himelein 2013, p. 10) which is similar to most regional averages, except for the Western Area: the capital Freetown and the densely populated belt that surrounds the city (World Bank 2013, p. 36). While
Kailahun might be lacking in infrastructure investment, in recent years, the district has once again been referred to as Sierra Leone’s breadbasket, producing some of the country’s most successful export crops: coffee, cocoa, kola nut and oil palm (UN
World Food Programme 2011, pp. 25-26).
7.3 Case C: Participatory Monitoring and Evaluation
7.3.1 The implementation of the Participatory Monitoring and Evaluation intervention
The PM&E intervention is the first of two cases implemented by a partner agency of
Christian Aid.60 Unlike the CM and NFA methodologies described in chapters five and
60 While in the introduction, I have referred to the agency that facilitated my research as Christian Aid Ireland, in Sierra Leone, the programmes funded by Christian Aid Ireland and Christian Aid UK were operated jointly by the Christian Aid Sierra Leone office. For that reason I will refer here to Christian 231 six, which were jointly implemented by four Sierra Leonean CSOs, the PM&E intervention was implemented by a single agency, the NGO SEND Foundation
(referred to as SEND throughout this document), which has its head office in Ghana, but has been operational in Sierra Leone for almost a decade.
The PM&E intervention that SEND implemented in Kailahun between 2011 and 2014 included a range of activities, all of which were designed to “improve the provision of primary healthcare by promoting good governance and downwards accountability within the health sector” (SEND, 2011a, p.1). The intervention was designed to provide citizens of Kailahun improved access to health facilities, and to be able to benefit from the healthcare policies provided by the Government of Sierra Leone:
Objective: support vulnerable communities to understand their rights to free health care and monitor and advocate for improved accountability in the health sector, especially as it relates to them, in partnership with District Budget Oversight Committee (DBOC); and to build the capacity of local government staff, particularly DHMT to better monitor key health indicators at primary and secondary health care level for improved transparency and coordination with other health actors. In line with the National Health Sector Strategic Plan (NHSSP) 2010-2015 Basic Package of Essential Health Services (BPEHS).
(Christian Aid 2010, p. 8)
The core activity, and the one that this study has focused on, was the ‘MDG awards’ competition - named after the Millennium Development Goals. It was named so because the free healthcare programme was introduced to improve Sierra Leone’s chances of achieving its health MDGs.61 Every year, for three years, SEND conducted a large scale survey of all 80 peripheral health units in Kailahun District (these
Aid (CA), as the international agency that facilitated the funding and technical support of the two interventions I studied in Kailahun and in Kono. 61 SEND conducted additional surveys among all target clinics, focusing on stocks of the FHCI medicine (one baseline and one follow up survey) and two surveys on how clinics spent the funds they received through the Performance Based Finance programme. For brevity, these have not been included in the focus of this study. 232 included all small, medium and large health facilities62, but not Kailahun’s two hospitals) to select the winning clinics (see Appendix E for a sample of the survey).
The vehicle for determining which clinics won the MDG awards (one award per small, medium and large sized health facility was conferred every year) was a large questionnaire, which had been compiled in a participatory manner by health workers,
Kailahun district health authorities (including the District Medical Officer) and the health chairpersons of Kailahun District Council. The objective of the survey was to
‘measure which clinics best implemented the Free Healthcare Policy’. It was not easy for the SEND team to come to an agreement with the health authorities on what should be measured, as SEND’s 2011 baseline report suggests:
Originally reflecting the standards of the [Free Healthcare policy], the criteria ended up being more watered down version cutting out any services for which government resources are required. Factors scored no longer include provision of any basic services, adequacy of sanitation facilities, ambulance availability and use, safety of water, staffing levels, or power supply. Certain fundamental requirements for effective front line primary care are, thus, no long reflected in the assessment.
(SEND Foundation 2011, p. 10)
It was clear that due to a lack of government support, not one single clinic in Kailahun was able to fully meet the healthcare provision standards set by the Ministry of Health and Sanitation policy. By watering down the requirements on the check list in such a way that a clinic without running water, electricity or a solar-powered fridge could still win the award, SEND felt it may have lowered its standards, but at least it did not demotivate the majority of clinic managers by setting the bar too high.
62 Some of the citations from the Christian Aid/SEND proposals refer to 74 PHUs. The number of PHUs in Kailahun expanded even before the intervention got underway, and by the latter half of the programme, the total number of PHUs had increased to 80 facilities. 233
The survey was directed at the healthcare staff at Kailahun’s 80 clinics, and it was deliberately focused on verifiable data only: scores for hygiene were based on visual verification and available cleaning rotas, and all documentation was checked by the enumerators: from the water treatment logs to the minutes of staff meetings or monthly meetings with the facility management committees (FMCs). The survey also included a short section that was to be filled in by a member of the FMCs, who, according to the
FHCI policy, are mandated to regularly oversee the delivery of care and witness the arrival of the free medical supplies. It was in this section that the survey incorporated scores for possible malpractices in the form of absenteeism, rudeness and charges levied for care that should have been free.
The MDG awards survey provided an interesting take on the ‘info out’ component.
Unlike most other social accountability interventions, in which an info-out component it usually designed to enable citizen to compare the service they receive with similar service providers in the locality (e.g. Björkman and Svensson 2007), in this case the design was different; the data gathered established in great detail which clinics in
Kailahun provided the best health service, but the main target of the information were the health workers and the district health authorities, more than the citizens.
The annual PM&E survey was preceded by an extensive ‘info in’ component; a community-based information campaign which was designed to inform the community about their entitlements to free healthcare. During the information campaign the community-based monitoring groups received training about their responsibility to hold health workers accountable for doing their job well. The information component included a range of complementary activities that were all designed to derive maximum benefit from the competition: the upward pressure from the community and
234 the FMCs’ greater awareness of their free healthcare entitlements reinforced the downward pressure applied through the incentive to win the MDG award.
The programme had an innovative way of raising awareness about the free healthcare policies. SEND had an ongoing women’s empowerment programme called ‘Kailahun
Women in Governance (KWiG)’ and SEND’s PM&E programme staff collaborated with the KWiG members to make a DVD with comedy sketches that illustrated the confusion about the free healthcare entitlements. Subsequently, the women’s groups across the district received support from SEND to link with the existing FMCs (who were also receiving training from SEND) to take the DVD to movie shacks and community halls throughout Kailahun to show the DVD. The KWiG women facilitated debates after the DVD was shown, to answer the audience’s queries. Workshop facilitators ensured that the role of the FMCs was discussed, in order to encourage greater engagement between the community and the health workers. In addition, the
KWiG members generated debate in the local media and their dedicated women’s radio programme regarding the quality of healthcare that was being provided throughout the district.
Meanwhile, SEND staff engaged community-based individuals known as District
Budget Oversight Committee members (DBOCs), and enrolled them into the health and accountability programme. DBOC offices exist throughout Sierra Leone, and were set up in 2004 to monitor the reconstruction of schools, health centres and other public facilities after the civil war. Individuals selected to become DBOC members were usually local teachers: people who were literate and were able to occasionally take a day off from their regular duties with Ministry of Education permission (Christian Aid
2010). DBOCs received a small government stipend for ongoing monitoring activities,
235 which made them an attractive group of people to work with for SEND: they were members of the local community, they had some monitoring experience and did not expect a ‘retainer’ (stipend) for the time they were associated with the programme. The
DBOCs became SEND’s lead enumerators; each chiefdom in Kailahun had its own enumerators’ team made up of a local DBOC member assisted by two or three members of the local women’s group. SEND staff occasionally accompanied the enumerators for quality control but it was largely the locally based DBOCs and women’s group members who visited each of Kailahun’s 80 PHUs to conduct the annual survey on the standard of healthcare delivery.
At the end of each annual survey the data was
analysed by SEND staff to decide which small,
medium and large-sized clinic won the MDG
award. Each of the three winning clinics received a
motorbike (for use by the clinic staff) and fuel
vouchers. Each winning clinic also received a cash
prize to share among the staff and a large sign
outside the clinic declaring its winning status.
Figure 9: Photo of a sign board declaring this clinic a MDG awards At every stage of the awards competition, the winner District Health Management Team was engaged.
The district health authorities were notified which clinics were shortlisted and a
DHMT member accompanied senior SEND staff to decide on the winning clinics.
DHMT staff were also centre stage at the awards ceremonies and were invited to join the SEND team to install the ‘winner’ sign boards (see photo).
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Before SEND implemented the PM&E intervention in Kailahun, the organisation already had experience of using the PM&E methodology in Ghana, the country where the organisation originated. The organisation’s experience with the PM&E methodology was explained by Siapha Kamara, the director of SEND (KI001), who spoke eloquently about the philosophy behind the method. He stressed that providing community-based actors (such as DBOC members) with sophisticated monitoring tools to regularly check up on their local service providers is much more effective than relying on communities to apply social pressure in a very ‘power-uneven’ situation.
Similarly, Kamara added, health workers are easier to motivate with a strong incentive than with social pressure.
This level of experience and confidence in a methodology was in marked contrast with the other organisations, most of which were first time implementers of the social accountability methods. SEND’s senior programme staff were predominantly from
Ghana. In my reflective diary I noted being impressed by the team’s professionalism:
At the end of the second day in the field with the SEND I noted: “Overall this organisation really impresses me, and I can imagine that anybody who works in this team will benefit from learning from the Ghanaians.” When I asked the director why he did not employ more staff from Sierra Leone, he replied that he found it difficult to find Sierra Leoneans who had the right capacity and who were willing to live in
Kailahun. According to his theory, there are so few well trained Sierra Leoneans, that everyone who is well trained has a range of jobs to choose from in the more comfortable and cosmopolitan capital, Freetown. In Ghana, he added, the general levels of education are much higher (KI001).
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Examining the PM&E methodology, it was clear that this method is located at the edges of what is called ‘social accountability’. As mentioned in the literature chapter, the boundaries of what can be called a social accountability intervention are notoriously vague. Even Houtzager and Joshi, who advocated for a tighter definition, still leave plenty of room for interpretation. Their definition, which I cited in chapter two, is: “[…social accountability can be described as] the ongoing and collective efforts to hold public officials to account for the provision of public goods which are existing state obligations” (2008, p. 3).
Defining social accountability in this way accommodates a lot of different ways of
‘holding accountable’ and promoting citizen engagement. It encompasses methods that focus on stimulating bottom-up demand and pressure for better services, and there are those that support various forms of top-down monitoring, or combine the two. SEND’s
PM&E methodology falls in the latter category, as do other methods that replicate, support or stimulate government-run oversight functions by running checks on service providers (National Taxpayers Association 2014). There are interesting examples of accountability programmes that use information technology to report on, for example, absenteeism (Duflo et al 2012), or independently carry out test in the community to see if the services provided have had the desired outcome (Uwezo 2015). All of these are examples of top-town monitoring approaches in which the implementing agencies focus on providing evidence of service provision shortcomings, in the hope that both governments and citizens react to the publication of these facts.
SEND’s intervention falls slightly in between the bottom-up and the top-down categories: the PM&E method worked with existing monitoring groups, such as the
Facility Management Committees, members of the District Budget Oversight
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Committee, and established community-based women activists to carry out their surveys. The surveys were designed to show the district health authorities how the monitoring of health services should really be done, and in the process the intervention promoted improved healthcare practices by rewarding the best clinic staff. SEND has used this method for almost a decade, and when I queried the lack of citizen participation in their ‘Participatory M&E’, SEND’s director Siapha Kamara pointed out that the participatory manner in which the monitoring check lists are compiled, is why the method is called PM&E. Before an intervention gets off the ground SEND holds a workshop with district health authorities, health workers and district council representatives, in which everybody gets to weigh in on how the ‘accountability of the health facilities’ will be evaluated. This, Kamara assured, “is the closest any of these individuals ever has come to really participate in an intervention that is conducted by an NGO in their district. By obtaining this level of buy-in, we usually overcome a great deal of resistance to our surveys” (KI001).
Within the comparative framework of this research, the PM&E method contained several components that none of the other interventions used:
This is the only intervention which contained extensive ‘info in’ as well as an
‘info out’ component (the latter being the MDG awards survey).
This is the only intervention in which each of the target clinics was surveyed,
using a fully transparent system in which the health workers received a copy of
the questionnaire in advance.
The questionnaire served as an information tool for health workers, who
admitted not always being made aware of the FHCI policies they were
supposed to implement.
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This intervention is one of two that ran a competition for most improved health
facility. However, this method is the only one that offered significant prizes: a
motorbike for the clinic, fuel vouchers and prize money to share among staff.
This intervention had by far the strongest links to the local health authorities.
The District Health Management Team members were involved in the survey
design and engaged at every awards ceremony, as well as SEND’s yearly
‘health summit’.
7.4 Assessing the Participatory Monitoring & Evaluation intervention
This section provides an examination of the implementation of the Participatory
Monitoring & Evaluation methodology. This section starts by presenting the findings from the health worker interviews and the focus group discussions and is followed by some additional observations about the intervention. The latter are based on advocacy publications and extensive quarterly and annual reports produced by SEND. In addition there are notes based on my observations and interviews with key informants and staff from the implementing agencies.
7.4.1 Findings – from the health workers’ perspective
The health workers interviewed about the PM&E intervention were positive about the programme. Out of eight ‘heads of health facility’ interviewed, seven clearly made an effort to win the MDG award, while one admitted he wasn’t that interested (HW27).
The efforts that health workers had gone to in order to win the MDG award varied: one
240 health worker admitted that he had taken time off, paid his own bus fare to visit the clinic that won the previous year (in the Community Health Centre category). He had interviewed the winning staff, had observed the changes that the previous year’s winners made and made a plan of action to replicate these in his own health facility.
His efforts paid off (HW01). Those in charge of smaller facilities ‘Maternal and Child
Health Posts’, clearly had a smaller budget to invest in making improvements, but interviewees who ran MCHPs still tried. One health worker proudly explained that she had personally constructed new shelving to store the clinic’s medication. She guessed it would be impossible for her health centre to win, because the facility was located in a former house, not in a dedicated clinic (HW04). The health worker (HW13) in charge of a tiny remote clinic, four miles from the Liberian border, was equally doubtful of his facility’s chances of winning (for the same reason, his clinic being housed in an unsuitable facility), but he explained that he still tried by making great efforts to fill in all the forms correctly and by keeping clear patient records. One health worker (HW17) commended SEND for “[…] taking on a role that is the government’s role. They ginger [encourage] people to come up to the standard that is expected of them. That is a very good initiative.” He added:
SEND has taught me a lot, now I am better with writing things down and displaying the clinic’s records, I can see that this is important. Proper documentation, keeping receipts, it is all accountability. Meetings too, before I used to have meetings with my staff by just talking like we do now, but I understand that it important that records are kept, so now we take minutes and store these.
Health workers were full of praise about how the awards competition had changed working practice among themselves and their colleagues. One noted: “[The MDG award] has restored cleanliness to many PHUs and encouraged the provision of basic materials: drinking buckets, hand wash facilities, stationaries. In past people were
241 feeling lethargic so they didn't provide them, because there was no reporting structure for those things, but now you rush to bring them because they can lose you points"
(HW24). On the whole, the majority of clinics I visited in Kailahun stood out in terms of wall displays which showed up to date disease prevalence, vaccination tallies, facility births and other statistics. They were also noticeably cleaner than some of the clinics visited in other district.
It was clear that not all health workers in charge could be swayed into better work practices by the lure of a competition. The clinic manager of a newly opened facility explained how an almost complete lack of furniture would surely hamper his clinic’s chances of winning, so he hadn’t tried very hard to make changes in other areas either.
He did add that he had made some improvements that he had seen on SEND’s check lists; he (HW24) had used the most recent Performance Based Finance (PBF) payments to buy a delivery bed, a mat and a bucket with a tap to provide the patients with drinking water. At the end of the interview he added that he was being transferred to another district to study ophthalmology, so there was little incentive for him to try winning the MDG award.
As mentioned, there was one other health centre manager (HW27) who had done nothing to try to win the competition. He claimed not to have seen the guidelines, and while he could remember why he did not score points on a few things the previous year, he admitted he never acted to improve his performance. It was clear throughout the entire interview that his focus was on earning as much money as he possibly could.
He explained in detail how “the government paid”63 extra for treating certain patients:
63 His assertion was incorrect; the World Bank paid for the Performance Based Finance salary top-ups, not the GoSL. 242
We go for outreach four times per month to vaccinate children in outlying communities. Before FHCI outreach was not common, but now the government encourages you to treat more patients. They pay for us to treat under-5s, the more we treat, the more we get paid for [with PBF]. The government pays for each fully immunised child, third post-natal care visit, facility delivery with partograph [the health worker keeps a record of vital statistics during labour], and other things too.
When asked, the same health worker (HW27) gave a detailed calculation of the last quarterly payment of PBF funds he received:
We received Le 2.9 million [approximately 670 US$], and I took 60% for the three medical staff as incentive [US$ 134 per person, which included the stipend for the in- charge himself], 40% for health centre investment. Out of that I paid Le 50,000 [11.50 US$] each for the four volunteers, Le 15,000 [3.50 US$] for each TBA, 14 of them. The rest was spent on outreach, as we need to pay for transport, and what was left on things such as soap and batteries, small repairs.
Given the level of a basic salary for a ‘health worker-in-charge’, it is obvious that the quarterly salary top up of almost a full month’s salary is significant.64 It is important to understand the existing incentives for health workers, as it is clear that the value of the prize on offer through the MDG awards needs to be considered in this context.
Whether the health workers’ record keeping for the purpose of the PBF payments was accurate is another question, it remains unclear whether the self-reported ‘numbers of patients treated’ was ever verified. As Stevenson et al noted:
One worker, who had apparently gained little from the first round of PBF, reported much larger numbers for the second round. When questioned, she replied “now we know how to fill in the forms”. It is not totally clear whether she intended the face value of these words and she is now more familiar with the requirements for completing the forms, or if she was indicating that she now knew how to manipulate the system to produce higher rewards. (Stevenson et al 2012, p. 23)
64 Several health workers and CASL staff confirmed that a basic salary for a Maternal and Child Health Aide, the most junior cadre of health worker who could be in charge of a small clinic, was around US$150 per month. While the PBF top up for the health workers was significant, it was hard to see how volunteers and TBAs could be ‘incentivised’ to come to work to earn between US$3.50 and US$11.50 or per quarter. 243
There were a few other notable comments from the group of health workers, several mentioned being motivated by winning SEND’s MDG award. A winning health worker (HW01) explained: “I feel empowered due to the MDG award, I notice that I am being taken seriously. For example, the District Medical Officer [whose office is nearby] comes to the clinic to notify me that drugs have arrived, so that I can requistion them and the drugs will arrive timely.”
Another MDG winner (HW07) expressed similar thoughts:
I am very proud of winning the MDG award, and it feels that DHMT often calls on the award winning clinics as examples. I was selected for UNICEF training, which I think it was due to my good reputation. And even things like getting a new battery for the vaccine refrigerator, I believe I get what I request because they know it will be well looked after.
It was not only the award winners who were happy with SEND’s intervention. One health worker (HW17) noted:
They are educating me, they are teaching me things that I didn't learn in nursing school. All I learnt in the past was confidentiality, now SEND has taught me it is good to display certain things about my practice on the wall. Each year SEND shares their award books […] it is not just something they do just once, every year they print a small booklet and they give it to all PHUs, so that we become familiar with the check list.
Remarks that were made by all of the eight health workers concerned the shortage of medicines. Every single clinic reported being short of some Figure 10: Trucks stuck on the muddy Pendembu- key drugs, and regularly Kailahun road, the ‘main’ road connecting Kailahun District with the capital Freetown
244 experiencing stock outs of even essential drugs. Many blamed the deplorable state of the road, which is a dirt track for the last 17 miles between Pendembu and Kailahun town (see photo), where supply trucks can get bogged down for days before they reach
Kailahun medical stores, the distribution point. The difficulties caused by the road condition were experienced first-hand during the research. Even though the field visit to Kailahun took place in November, which is during the dry season, the roads were still boggy. Within a six-day period, roughly five hours were lost due to the bad roads, and within a week the research team’s vehicle towed nine other vehicles out of the mud in order to make certain stretches of road passable.
7.4.2 Findings – from the healthcare user’s perspective
The focus group discussions in Kailahun stand out in comparison with the other FGDs for its lack of focus on charges being levied for free care: it appears as if informal charges were less common here than they were in the other locations. While the four social accountability interventions will be compared to one another in detail in chapter
9, there is no avoiding the fact that this was unusual, given the pattern previous focus group discussions had started to display (see figure 11).
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Figure 11: Illustration of incidence of alleged charging for free care, raised during FGDs
10 9 8 7 6 5
4 3 No charges for free care 2
clinic 1 mentioned 0 Problem with charges for free care discussed Number of FGDs aboutnearby
The focus group discussions took place in eight locations in Kailahun where the
PM&E intervention was being implemented. In each location I interviewed the health worker in charge, and where possible either representatives of the local Village Health
Committee or a volunteer who worked at the clinic. The focus group discussions took place in the vicinity of the clinic and were usually conducted among a group of 6 to 10 women, most of whom were either pregnant, lactating or had children under five. As the PM&E intervention did not revolve around community-health worker dialogue, the discussants were often unaware of the intervention that had taken place.
The key complaint that was raised in every focus group was the lack of free healthcare medication, which was keenly felt throughout Kailahun’s clinics. The women who were interviewed generally assumed that the terrible state of the road had a lot to do with the lack of medication, but it was clear that nobody had been given an explanation as to why the drugs were in short supply. When medication was out of stock, patients were usually given prescriptions to buy the relevant drugs at the nearest pharmacy, which was not always a satisfactory solution, as pharmacies can be located far away
246 and did not always have the right drugs in stock either. There was no mention of any patient being offered ‘cost recovery medicine’ for which they would have had to pay.
While the drugs shortages meant that free healthcare-entitled patients in Kailahun often ended paying for the medicine they needed, the fact that they did so after being prescribed medicines that were out of stock and were not asked to pay for cost recovery drugs, indicated a small but crucial distinction. It was commonly assumed that medicines were only really out of stock if patients were provided a prescription. If patients were told they could buy cost recovery medicine because the free healthcare drugs had run out, it was possible that a health worker ‘sold’ free healthcare medicine, exploiting the fact that patients would be unable to tell the difference.
When it came to changes that were attributable to the PM&E intervention, there were quite a few. The majority of focus group participants knew little about SEND’s programme, but many women had noticed that changes had occurred in their local health facility.
Overall it is difficult to attribute all the changes the focus group discussants mentioned to SEND’s intervention. During FGDs the women often credited many of the improvements they had witnessed to the ‘Free Healthcare and the monitoring’, as both were introduced around the same time. Only in one case did the women remember the time the free healthcare was introduced, but SEND’s monitoring had not yet started.
The women were asked if they remembered any “accountability problems, even when
FHC first came?” Their response was (FGD23): “Yes, before the monitoring they were even extorting money from us, small small [...]. But since the monitoring came, they don't ask for money any more. Only problem is drug shortage.” 247
During FGDs, the women recalled many changes to the way in which healthcare has been delivered in recent years. The majority agreed that the monitoring was an essential part of the delivery of the FHCI, but struggled to distinguish between the two.65 In Kailahun, the monitoring of the FHCI was carried out by at least two CSOs66, so it was hard to distinguish which intervention was responsible for which impact.
Some improvements were clearly attributable to the SEND intervention: the MDG award checklist included a number of ‘easy to accomplish improvements’, such as the provision of drinking water and handwashing facilities with soap, which were acted on by the majority of clinic managers. These changes were often highlighted by focus group discussants and can be interpreted as being attributable to the PM&E intervention. The women interviewed during one focus group had not heard of the
PM&E intervention, but when asked if they had noticed any improvements at their local clinic, they responded (FGD02):
We have seen changes, there's soap and water for hand washing when you enter clinic. The tiles on the waiting room floor area are new, the place is cleaner. The tap is now working, there is running water. There is electricity inside, it is working most of the time, maybe by solar or generator. They now purify the water that is available for drinking- you can taste it. There are new benches to sit while waiting. The nurses now talk to you better than before [friendlier]. They are now giving health talks, especially on baby care, exclusive breastfeeding for 6 months. They talk to you about sanitation, they reprimand those who don't keep themself and their baby clean. It's good, they may tell you off, but it is for good reason. The nurses use dancing and singing to give health talks.
65 In order to see whether the changes the FGDs mentioned were due to free healthcare or to the monitoring, the women were asked if they felt they could attribute the changes they mentioned to FHCI, monitoring or both, and all but FGD23 said both. 66 Health for All Coalition, which had a nationwide monitoring mandate, and SEND; many other agencies came to check on particular supplies they provided, e.g. CARE distributed malaria medication in Kailahun. 248
Similar changes were remarked upon during another focus group (FGD08): asked if they had noticed any changes that they felt were because of SEND’s monitoring, the women answered:
Yes. We have noticed more cleaning, hand washing and better sanitation, since SEND started monitoring. The Facility Management Committee has encouraged the community to get more involved in protecting the waterpump used by the clinic. The community is now aware that we also need to collaborate. Every Wednesday the women come to the clinic and they have a cleaning session.
Cleanliness and health talks were also mentioned in an area where a new clinic had just been opened, where some FGD participants had heard about the awards competition and had seen changes even in the short time the facility had been opened: “We know there is an award for best performing centre, best kept centre. Clinics get points if health talks are being given. Cleanliness is important.” When asked if the women had seen the health workers make an effort to win the award, they (FGD28) replied: “Yes, we have seen them fencing off the area around the clinic, cleaning, we have seen changes. The MCH aide here is doing her best.”
Another focus group (FGD18) stressed the renewed involvement of the FMC, and how this has had a positive impact:
The FMC members have started giving health talks, and coming into clinic to check on patients: I don't think they see anybody collecting money from the pregnant women and lactating mothers, but they always ask. They even check on deliveries, making sure the TBAs don't ask any money.
[In response to a question about changes in clinic:] The nurses now also give health talks, the women listen to them, you see the change: previously women brought their children to clinic, and they were dirty, now they come with clean children. Handwashing is happening a lot more too, due to monitoring [hand washing water installed in clinic], and the 6-months breastfeeding they talk about, it is helping the children a lot.
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It is hard to imagine the impact a lack of accessible healthcare has had on the women of Sierra Leone. When a woman stated that the free healthcare and the monitoring had had a positive impact on infant mortality, it seemed like a preposterous statement to make. However, during one focus group discussion (FGD11), I wondered out loud if any of the six discussants had ever lost a child, four of the women silently raised their hand. The translator asked a few short questions and added: “they all died before the free healthcare.”
One FGD participant (FGD11) highlighted the plight of the traditional birth attendants in the area:
I want to make a special appeal, the TBAs are not on payroll, they only get a small token from this PBF, they have an investment fund, and they pinch a little bit from this incentive fund for the TBAs. These TBAs are hard workers. So I am appealing [to your organisation] that they should be considered, if even a meagre sum can be laid down to motivate them [...]
This appeal was probably motivated by the fact that an NGO had recently worked with
TBAs in the area, trying to re-focus their energies from assisting women to give birth at home to encouraging women to attend the clinic for ante-natal visits and delivery.
The former coordinator of the programme (KI20) explained that the programme had helped to motivate the TBAs to continue supporting the local clinics, even though the rewards the clinics could offer (using PBF funds) would be small. The intervention helped to create a greater understanding (among TBAs, health workers and the community) of the change of role for TBAs. In some places this had led to the community deciding it would pay a small ‘gesture’ to the TBAs each time they were assisting in the local clinic. In other locations the intervention helped TBAs to pool their resources to invest in, for example, the buying of palm oil at harvest time, when it is cheap, which TBA groups would store and sell when the price had risen. As the 250 appeal from the focus group discussant shows, once people were made aware of the fact that TBAs are often working at clinics for free, they are usually thankful of their assistance and willing to provide a small financial incentive. While this made the healthcare provision less free, it did make it more workable, especially in the smaller clinics where sometimes only one, or maximum two, staff on payroll relied on the help they received from ‘volunteers’.
7.4. 3 The Participatory Monitoring & Evaluation implementation challenges
SEND provided by far the most extensive range of documentation about the PM&E programme. Due to its continued focus on surveying the 80 target clinics, the available documents contained details about, for example, annual data on the overall performance of the health facilities and, particularly worth highlighting here, the activities of the Facility Management Committee.67
Sections from SEND’s 2011 MDG awards report, reflect the overall standard achieved by the winning health facilities in the first survey. Several short quotations from the report illustrate the shortcomings of even the best facilities in Kailahun: “None of the
Peripheral Health Units has the required staffing complement stipulated in the
BPEHS68 [the Sierra Leone Government’s Free Healthcare Policy]. Pendembu
Community Health Centre had 7 out of 14 required staff, Levuma Community Health
67 The term Village Health Committees (VHCs) was used in SEND’s documentation because at the start of SEND’s programme, Facility Management Committees (FMCs) had not yet been set up. To avoid confusion, I have changed all references to VHCs to FMCs. At the start of SEND’s intervention, most clinics had a VHC but their level of activity ranged from active to dormant. In 2012 the Government of Sierra Leone mandated that every clinic should have a FMC, and all VHC were either replaced by, or transformed into FMCs. 68 BPEHS means Basic Package of Essential Health Services, it is one of the few policy documents that was published at the time of the introduction of the Free Healthcare Initiative, and it describes the package of health services that all pregnant women, lactating mothers and children under five are entitled to for free. 251
Post had 4 out of 9, and Siama Maternal and Child Health Post had 3 out of 6. In total there should be 29 paid staff at the 3 PHUs, but there are only 14” (SEND Foundation
2011b, p. 14). The same report furthermore notes:
Generally, staff are not adhering to [government policy] guidelines regarding the operations of the solar power system, fridge, drugs and record keeping, water management, communications, supervision and monitoring activities. For example, the recommended maintenance schedule for the solar panel used to operate the drug cold chain is not being complied with. The DHMT is responsible for servicing the equipment but does not respond in a timely manner when faults are identified and reported by the staff.
(SEND Foundation 2011b, p. 15)
In order to improve the effectiveness of the Facility Management Committees throughout the course of the intervention, SEND started by collecting data on the relationship between clinics and the FMCs during the first district-wide survey.
Startlingly, the survey showed that the most common type of information the FMC members reported receiving from health workers during monthly meetings was health education. The report notes that
[…other topics such as the] use of resources at the facility, and financial assistance received were each mentioned by less than half of the respondents […]. Information on drug supplies received was reported by less than 10% of FMC members. Statistics on health indicators and service delivery were the other two major categories of information reportedly received by FMC members, but they were each mentioned by a minority of respondents (between 15-25%). (SEND Foundation 2011a, pp. 71-72)
Reflecting on the unexpectedly high scores given by the FMCs when surveyed about their satisfaction with the local health facility, the report furthermore notes: “High levels of satisfaction may indicate good relationships between FMC members and clinic staff; however, they may also be a result of a limited understanding of health
252 rights and the intended function of the health facility. An individual may report satisfaction if they are unaware of the standards” (2011a, p. 73). The report also noted:
These findings suggest that the majority of FMCs in the district may not be fulfilling their intended function as accountability structures, and as an avenue for information about PHU resources to the community. There is also significant discrepancy with findings from the PHU management survey, as 93.4% of PHU managers stated that financial support from the government is reported to the FMC at meetings.
(SEND Foundation, 2011a, p. 72)
Overall, the programme team estimated that a small percentage of the health workers ignored the competitions and made no improvements to the health service they provided. The research confirmed this. While this was to be expected, it was clearly frustrating for the SEND team, who displayed high levels of dedication to the programme. The SEND director and programme staff hinted at problems with the
DBOC members, who were not as reliable as the organisation had hoped. DBOC members already received a small stipend from a donor agency for continued
‘oversight duties’, and it was for reasons of sustainability that SEND had chosen to work with the existing oversight body. However, many DBOC members had long stopped fulfilling their budget oversight duties (but happily continued to receive payments), as the frequency of new infrastructure projects dropped off. Additional duties in the form of attending SEND meetings raised expectations of additional stipends, which could not always be met. SEND did pay DBOC members for the days they were engaged in enumeration activities. These duties were supposed to be shared equally with members of the women’s groups, but their low literacy levels (only 22% of women in Kailahun could read or write, according to a 2008 demographic survey) made it difficult for them to conduct the surveys without a DBOC member (KI30).
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For the local health authorities the cost of the MDG award’s prizes for best clinics was a problem: SEND allocated US$10,000 for the MDG award prizes every year –
US$4,200 was the cost of three motorbikes and the fuel and cash prize amounted to
US$2,500 for the largest clinic and US$1,650 for the medium and smaller clinic. In the eyes of a district health authority official, the substantial cost of these prizes made it impossible to replicate the programme whenever SEND phased out. While this criticism is fair, it has to be put into context: the cost of implementing the free healthcare is enormous - WHO estimated that the introduction of the free healthcare cost US$ 35,840,173 in 2010 alone (WHO African Health Observatory no date) and the research has shown that its actual delivery left a lot to be desired. If an intervention was found to significantly improve the free healthcare delivery, it would undoubtedly be worth the additional expenditure (such as the cost of MDG award prizes) to ensure the much larger investment into free care would be well spent.
However, for the district health authorities to adopt SEND’s MDG awards approach, it would have needed much more than sufficient funds to purchase prizes, or the data analysis capacity SEND had. Before the SEND intervention took place, most remote clinics in Kailahun received barely one or two supervisory visits a year, the main constraint to supervisory visits being the health authority’s lack of vehicles, fuel and per diems (KI26). The latter was as important a constraint as the former, and as a result, supervisory visits were often carried out as an add-on activity, during field visits which health authority staff conducted if they were paid by donor-funded health initiatives.69 Given the minimal effort that district health authorities appeared to be willing to invest in their daily duties, it seems unlikely that anything like SEND’s
69 In my five-week period of field visits, I witnessed health authorities, including the District Medical Officer, travelling around the health centres with health-focused NGOs or donor agencies on visits to promote malaria treatment, TB treatment, contraceptives, and malnutrition awareness. Clinics on the main roads close to the district capital received most visits, the remotest facilities hardly any. 254 competition would ever be implemented by the district health authorities alone, even if similar prize money would be made available.
7.5 Analysis
This section uses the analytical framework to examine how the PM&E methodology incorporated the four key social accountability ingredients: i) redressing information imbalances, ii) citizen participation, iii) power and political awareness and iv) sustainable staff motivation.
7.5.1 Redressing information imbalances
An analysis of the PM&E intervention shows that the programme had two separate information components. The first component was the ‘info in’ community awareness campaign that was implemented at the start of the intervention and was designed to promote the communities’ demand for greater accountability and better health service delivery. The FHCI information campaign that SEND organised at the start of the intervention followed a well-thought out strategy, it involved training key individuals in communities throughout Kailahun, who were tasked with cascading the knowledge down to their colleagues or communities. The programme document lists the total number of individuals trained:
1,110 Village Health Committee members 122 government health workers 74 chiefs 5,320 members of Kailahun Women in Governance (an ongoing SEND programme) 255
74 mammy queens (village based women leaders) 240 members of Reading Circles (also a SEND initiative) 29 District Councillors 4 District Council staff 15 District Budget Oversight Committee members
The extensive list of people targeted for training on FHCI entitlements shows that the intervention was serious about reaching all authorities and all individuals who may be able to disseminate this knowledge. A professional theatre group was hired to assist a group of Kailahun Women in Governance (KWiG) representatives during the making of a DVD about the free healthcare. This appears to have been the right tool for the widespread dissemination of key healthcare messages: it suited the environment in which the information needed to be communicated; it was suitable for an illiterate audience; the DVD format was novel and attractive; and all of the acting was done by local women who spoke the same language and the same dialect as the audience. The
DVD screenings were followed by dialogue sessions about the free healthcare, which were facilitated by KWiG members. In addition to showing the DVDs in movie houses and community halls all around Kailahun, the KWiG project used its broadcasting slot on the local radio station, Radio Moa, to broadcast three panel discussions on health care policies as part of its twice-weekly Women in Governance programme.
Despite these efforts, the general level of knowledge about the FHCI encountered during the FGDs was mixed. Some women reported being told at a rally [SEND workshop or subsequent women’s group meeting] what the free healthcare policy meant, while others reported hearing about it on the radio; one group mentioned watching the DVD. It appears as if this ‘info in’ component had the potential of being power-redressing, in the sense that it certainly equipped most women who heard the radio shows, watched the DVDs or took part in a training session with the right
256 knowledge about free healthcare entitlements. Whether or not women felt empowered by this knowledge is another question. It can be envisaged that a sick woman on her own, or with a child, may still not have plucked up the courage to confront a health worker over incorrectly levied charges, even though the patient may be aware of this.
This brings the debate on the redressing of information imbalances and the rebalancing of power to another point: the research seems to suggest that in order to do so successfully, citizens need to be both provided with the right information but also the right opportunity to redress the power imbalance? In other words, is it necessary to create an opportunity for citizens to confront service providers with the knowledge they have acquired in a safe space, such as a well-facilitated interface meeting? There was not enough evidence to conclude that this is always the case, but the issue warrants greater investigation.
The second component was the MDG awards intervention, which was centred on an extensive annual health facility questionnaire (a form of ‘info out’). The objective of the survey was to establish how well clinics were adhering to the free healthcare policy, and to highlight and reward the best performing clinics. In the process it encouraged improved health worker performance by awarding the competition winners with significant prizes.
While the survey was not deliberately designed to inform health workers about their duties and responsibilities, health workers noted that it was a useful tool. Many of the healthcare staff appreciated the ‘guidance’ that the questionnaire provided, even though this had not been intended as such. The repeated mentions of the utility of the clear guidelines that the SEND questionnaire provided shows the need for better guidance on basic health policies among healthcare staff. Several health workers
257 commended SEND for printing booklets after each MDG award, which were distributed among all health facilities. The booklets contained the check-list, and some health workers noted that they had continued to refer to the list throughout the year. In several cases, the checklist was found tacked to the wall over the desk of the health worker in charge.
Overall, the information components of the PM&E intervention were clearly successful, even though the evident lack of awareness of the free healthcare policy among some of the healthcare users showed just how difficult it is to sensitise a large rural community, even with the right tools.
The health workers’ need for clearer guidance on the new healthcare policy was not picked up on by the agencies that implemented other interventions, and could be explored further, as there are several successful examples of providing treatment protocols, check lists and policy guidance in the human resources for health literature
(Das et al 2012, Mathauer and Imhoff 2006, Trap et al 2001).
7.5.2 Citizen participation
On the citizen participation component, the PM&E intervention paints a mixed picture.
The intervention did not engage citizens on a large scale. At village-level the PM&E method focused primarily on improving the engagement of the existing Facility
Management Committees by providing training about the rights and responsibilities of
FMCs. The small FMC survey (which was conducted alongside the clinic survey), interrogated FMCs’ views of the community’s satisfaction with the local health services, and created some room for citizens’ voice. However, given that many FMCs were unengaged with key health service delivery issues, problems between the health 258 workers and the community were likely to have been overlooked. As the survey documentation showed, at inception, the level of engagement between the FMCs and the health facilities was far from satisfactory, with topics of discussion during monthly meetings providing evidence that the FMCs were not asking the kind of questions that one would associate with holding health workers accountable. Subsequent survey reports continued to expose weaknesses in FMC performance, with notes on the shortcomings of winning clinics in 2012 referring to “inadequate evidence of financial accountability to FMC” (SEND Foundation 2012, p. 14). The focus group discussants, however, did indicate several times that the FMC in their village had become more active as a result of SEND’s engagement, so there was clearly some improvement.
As the awards competition led to greater improvements in healthcare delivery in
Kailahun’s clinics as the PM&E programme progressed, the role of the FMCs seems to have become less relevant to the programme, the health workers and the communities.
The intervention seems to have achieved improvements in health worker behaviour, but not necessarily engendered greater downward accountability to the dedicated local oversight organ, the FMCs.
7.5.3. Power and political awareness
The PM&E intervention was clearly designed with sufficient awareness of the power dynamics between health workers and citizens and between health workers and the district health authorities. The intervention’s designers were clearly cognisant of the political considerations among those who were responsible for the supervision of the primary healthcare workforce in the target area. Programme documents contain explicit mentions of the shortcomings of accountability mechanisms throughout the
259 primary health sector in Kailahun, such as: “Weak institutional capacity and poor governance at DHMT level limits its ability to deliver and coordinate effective maternal and child health services, fulfil oversight function and ensure accountability in procurement and budgetary and M&E processes” (Christian Aid 2010, p. 9).
By choosing District Budget Oversight Committee members as their lead enumerators, the designers of the PM&E award demonstrated their local power awareness. DBOC members had an official oversight responsibility and could therefore not be brushed aside by health workers who were unwilling to collaborate during the completion of the MDG questionnaires.
The PM&E programme design included multiple interventions that aimed to strengthen the capacity of the DHMT. Activities included regular meetings with
DHMT, the engagement of health officials at all awards ceremonies, and the joint organisation of an annual ‘Kailahun Health Summit’ kept the health authorities fully informed of PM&E programme and the DHMT’s M&E staff engaged with the surveys. The programme was designed to encourage behaviour change among DHMT staff and inspire them by showing the positive effects thorough monitoring and competitions can have. As Kailahun’s District Health Nurse (KI21) put it “the awards praised the health workers for what they are doing right; this was never tried before, but it seems to work.”
At frontline service provider level, the programme also displayed an acute awareness of the accountability failures that were common. Inappropriately charging user fees was one of the many check list items for which clinic staff could lose points and undermine their chance of winning the MDG award. Instead of trying to tackle the issue of charging head-on, the PM&E intervention presented it as a choice between
260 continuing unaccountable behaviour or having a chance of winning the MDG award.
The designers of the intervention further demonstrated their power awareness by not trying to do what was close to impossible in this context, empowering citizens to hold service providers accountable.
7.5.4 Sustainable staff motivation
The staff motivation component of this intervention was by far the strongest of any of the social accountability interventions examined for this study. It started with the deliberate collaboration with the local health authorities and with a number of health workers to ensure that the checklist on which the clinics were being scored was considered to be a fair reflection of how health workers should implement the government’s healthcare policies.
The awards competition appears to have been well designed, with the incentives, the motorbike, fuel and cash prize, being of such significance that it could persuade individuals to make an effort in order to win the prize. Given that it was well known that some of the unaccountable behaviour was lining the pockets of the health workers,
SEND clearly designed the prizes to be of the right magnitude to make it worth the potential financial loss in order to try and win the award. The transparent manner in which the questionnaire was filled in and the scores made public, seems to have added additional confidence to many of the health workers that this prize really was within their reach – and that the process itself was not corrupt.
Overall it appears as if the positive attention that was generated by the award created an environment in which health workers felt appreciated and listened to. One health
261 worker (HW17) noted the necessity of monitoring, but also the importance of how it is done: “NGOs have been continuing to monitor after the government declared victory after the first day after the free healthcare. Some NGOs, like SEND, enquire in a good way, others 'police', in negative way.”
Having reviewed the literature that exists about problems with the primary healthcare sector in Sierra Leone and conducted field research for this study, I believe that the level of intrinsic motivation among Sierra Leone’s primary healthcare workers was generally quite low. The research suggest that the nature of the award offered by
SEND’s intervention, and the tactful way in which the competition was held, presented little risk of damaging health workers’ intrinsic motivation. Indeed, the positive assessment of the majority of the healthcare staff, seemed to suggest that partaking in the MDG awards competition may have led, in a number of cases, to an increase in health workers’ intrinsic motivation.
7.6 Conclusion
The Participatory Monitoring and Evaluation intervention has provided this study with an opportunity to examine what can happen when an ‘awards for improved practice competition’ is combined with clear direction provided to health workers as to what standard of care should be aspired to, and in addition, a significant prize is attached.
Not only did the intervention provide a second example of a ‘competition for improved health worker practice’ method, the explicit focus on ‘top-down monitoring’ of health facilities provided an interesting contrast to the methodological approach taken by two of the other social accountability interventions under study. In addition, the 262 intervention was carried out in a different manner professionally. SEND was the only agency which had carried out this type of intervention many times before. As the case study evidence shows, the awareness of the political economy of healthcare delivery in the district where the intervention was implemented also appears to have contributed to this method’s success.
Evidence suggests that the differences in political awareness, in professionalism and familiarity with the methodology were all factors that contributed to the success of this intervention. I note that some of these factors fall outside the analytical framework that was used for this study. In chapter nine all four interventions will be compared and the analytical framework for this study will be examined to see if it was sufficiently all- encompassing to provide a rigorous framework that included all the key components that are necessary for a successful social accountability intervention.
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Chapter 8 - Case Study D: Mixed Methods with
Quality Service Circle
8.1 Introduction
This chapter presents the evidence from case D, the Mixed Methods with Quality
Service Circle intervention. This intervention was implemented by the NGO Network
Movement for Justice and Development (NMJD), which was one of Christian Aid’s local partner organisations. The intervention took place in Kono District, which will be introduced in section 8.2. Section 8.3 provides details of the many components used in this intervention, including the Quality Service Circle methodology. Section 8.4 presents the findings from the field work, including interviews with members of the
Community Health Monitoring Volunteer Groups (CHMVGs), which were the cornerstone of NMJD’s intervention. Section 8.5 uses the analytical framework to examine the evidence that was gathered during the field research. Section 8.6 concludes.
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8.2 Setting and historical context: Kono district
Kono District is situated in the
east of Sierra Leone. It borders
Guinea to the east, and Kailahun,
Kenema, Tonkolili and
Koinadugu Districts to the south,
west and north. Kono District is
Sierra Leone’s most ethnically
diverse district and it is populated
by people who belong to the Kono tribe, along with a sizable proportion of migrants from other parts of Sierra Leone who have settled in Kono over the decades. Because of its ethnic diversity, and the Sierra
Leoneans’ tendency to vote largely according to their ethnic affiliations, Kono is often referred to as Sierra Leone’s ‘swing state’ (Africa Research Institute 2011, Africa
Confidential 2012).
Kono has been a centre of artisanal and industrial diamond mining for more than half a century. One of the first major ‘diamond rushes’ to Kono District took place shortly after the Second World War and prompted fears among colonial officials that the bonds of traditional communities were under threat (Fanthorpe and Maconachie 2010, p. 262). Chiefs have always been powerful brokers in the mining economy, authorizing the local settlement of rich and poor migrants and serving as middlemen between mining investors and landowners. This has led to ambivalent relationships between chiefs and their communities, as ordinary citizens have come to realise that chiefs
266 often maximize profits for their own gains and that of their immediate families, not necessarily for their communities, as Fanthorpe observes:
Deference towards chiefs is greatest in remote agrarian communities but declines sharply in urban areas. The exception to this pattern is Kono District, whose historic diamond industry and unique identity politics enabled chiefs to amass wealth and influence as political brokers. However, more than 50% of survey respondents in Kono were in favour of transferring responsibility for revenue collection from chiefs to local councils. These results suggest that public deference towards Kono District’s powerful and wealthy chiefs is as much pragmatic as it is ideological.
(Fanthorpe et al 2011, p. 5)
Kono’s diamond wealth has meant that the district has always been subject to intense political meddling from outside. Fanthorpe and Maconachie have described the concerns of the colonial government during the first diamond rush, as well as of successive post-colonial governments, most notably under Siaka Stevens’ rule (1968–
85), he “[…] attempted to manipulate the complex politics of diamondiferous areas for their own hegemonic ends. The governing elite in Freetown frequently intervened in chieftaincy elections to ensure the election of regime loyalists, and regime insiders were given preferential access to mining licences on prime sites” (Fanthorpe and
Maconachie, 2010, p. 263). Kandeh adds further detail about the wheeling and dealing in the diamond rich districts in that period:
Malfeasance in the Stevens dictatorship afflicted all levels of state administration. In the public bureaucracy, for example, the president's secretary and head of the civil service tasked his subordinates to falsify documents and inflate financial expenditures. Abdul Karim, the official in question, patrimonialised the civil service by operating an elaborate tribute system of appointments and promotions based on bribes. To be appointed district officer in the diamond mining town of Kono, a civil servant had to pay Karim an initial bribe of Le 10,000 (the equivalent of ten thousand U.S dollars at the time) and monthly payments of Le 8,000 to keep the job. Appointment and retention of provincial and district administrators in non-mining areas were based on the same corrupt, neofeudalist formula, with appointment bribes of Le 7,000 and monthly retention payments of Le 3,000. (Kandeh 1999, p. 352)
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During Sierra Leone’s 1991-2002 civil war, fighting was intense in Kono District. As discussed in chapter four, observers and academics generally agree that the civil war was not started by the RUF rebels in a bid to gain access to diamond rich territory, but that the profitable opportunities from controlling such areas were not lost on any of the warring parties. All groups involved, including some peace keeping battalions, sought to enrich themselves during the war; some bought weapons, ammunition and foot soldiers with the income diamonds brought (Keen 2003, pp. 67-70, Reno 1995,
Richards 1996, Richards 2003), fuelling the conflict further.
At the end of the civil war, a second ‘diamond rush’ took place in Kono. The new wave of migrants included many ex-combatants who never joined the post-war
‘disarmament, demobilisation and reintegration’ programme. Many of these men continue to reside in Kono, some still digging for diamonds (Bøås 2013), though many young men are now increasingly unemployed, as the diamond industry has shifted into more industrialised, and less labour intensive methods in recent years.
The large numbers of day labourers and unemployed youth led to a post-war development that is unique to Kono: a series of mining advocacy groups sprung up, organising groups of idle young men into self-help groups and activists, raising questions about governance issues that surround the mining industry. While commentators initially saw this as a promising new sign of post-war indigenous organisational life, Fanthorpe and Maconachie point out that it did not take long for
Sierra Leone’s two dominant political parties to entice the leadership of the most successful mining advocacy organisations into their ranks, after which the advocacy of the most noticeable group largely stopped (2010, p. 265). Subsequent mining advocacy groups were established and a number of these still exist. It is difficult to establish
268 whether these groups have managed to improve the life of diamond diggers or of the communities that have been displaced by the diamond industry. The emergence of civil society groups may have started several years earlier in Kono than it did in other districts in Sierra Leone, but many such groups appear to suffer from the same weaknesses as the majority of Sierra Leonean civil society groups: little capacity and weak governance (Campaign for Good Governance and CIVICUS 2007, 2014).
NMJD, the organisation that implemented the Mixed Methods intervention that is focused on in this chapter, has its origins in civil-war era relief and post-war mining advocacy.
8.3 Case D: Mixed Methods, including Quality Service Circle
The Mixed Methods with Quality Service Circle (MM/QSC) intervention, the fourth and final case examines the intervention of the NGO NMJD, funded by Christian Aid
Ireland. Similar to the PM&E intervention, it was implemented by a single agency.
NMJD was the only agency in this study that had a pre-existing relationship with its international NGO donor, Christian Aid, which has supported several NMJD projects in the past.70
For this intervention, NMJD implemented a range of activities under the project title
‘Community Health Monitoring for Accountable Health Services in Kono’. The ‘social accountability component’ of this intervention was the implementation of the ‘Quality
Service Circle’ (QSC) method, used to bring citizens and service providers together in
70 The four implementing agencies that were funded by Concern to implement the CM and NFA interventions had no prior relationship with Concern (KI76), and neither did SEND have any prior engagement with Christian Aid. 269 a bid to improve their relationship. Tied into this component of NMJD’s intervention was support to members of the local FMCs, the pre-existing community-based health monitoring groups, which NMJD retrained and called Community Health Monitoring
Volunteer Groups – CHMVGs. The objective was to improve the CHMVGs’ capacity to hold health workers to account in the ten target clinics that were selected for
NMJD’s intervention. The 9-member CHMVGs were formed by engaging and training all five members of existing Facility Monitoring Committees and adding four individuals from four outlying communities to these groups. The original CHMVG members were located in the village where the health facility was based, but by adding members from neighbouring communities, the CHMVG were expected to train and mobilise a larger health user population to hold their local clinic staff accountable for the health services they provided. The CHMVG, unlike FMCs, received a small stipend from NMJD for their monitoring efforts, for the duration of the project.
NMJD’s health monitoring project was anchored in their support for the CHMVGs but it contained many additional activities, which prompted my decision to refer to the intervention as ‘Mixed Methods’. As stated, the intervention included a Quality
Service Circle element and budget literacy training for the CHMVGs so that they could engage with health workers in the planning of discretionary spending for clinic maintenance or improvements.71
The programme also included a radio listening group component: NMJD, together with several other NGOs in the health sector in Kono, jointly produced a series of radio programmes on healthcare information and entitlements. These programmes
71 All clinics received quarterly Performance Based Finance payments. Sixty per cent of the funds were intended as motivational salary top-ups while 40% was supposed to be invested in the health facility. This 40% share should be used according to the joint spending plan agreed between the health workers and Facility Management Committees. 270 were aired on local radio, and listened to by the ‘radio listening groups’ which the
CHMVGs established in the ten target villages and in surrounding areas. NMJD provided a radio for each of the 50 radio listening groups, one for each clinic-based group, and forty for the groups established by the CHMVG members in the outlying villages. In the second half of the programme’s implementation period, NMJD decided to add a ‘community self-help component’ to the activities. This component provided funds which, combined with financial contributions and free labour provided by the community, led to the beginning of the construction of housing for the healthcare staff or waiting rooms for pregnant women who live far from the clinics. In three locations the health workers and community members opted to not construct any buildings but asked NMJD for funds to buy a generator for the clinic, which were granted. At the time of the data gathering field work in May 2014, most of the construction projects had not progressed much beyond the manufacturing of clay bricks by the community.
Within the comparative framework of this research, this method contains several unique components:
This is the only intervention which used ‘an iterative approach’ in their implementation methods. Social accountability literature often calls for interventions to be more open to change within the intervention (Tembo 2012), doing more things that work or abandoning things that do not work and responding to the communities’ needs (such as trying to help communities build staff houses or waiting rooms for pregnant women). While in this particular case, the iterative approach was more by accident than by design, it still provides a completely different model compared to the other interventions. This intervention had the strongest community focus, albeit a focus that mainly engaged a small group of community representatives, who created the opportunity for the implementing agency staff to be repeatedly in touch with
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the community and gain an understanding of the community’s needs and challenges. This intervention had some links with the local health authorities, with District Health Management Team members attending several citizen-service provider meetings (though not consistently in each of the ten target communities).
8.4 Assessing the Mixed Methods with Quality Service Circle intervention
This section provides an examination of the MM/QSC intervention. Because there is a lot of information which needs to be considered prior to the assessment of the empirical evidence, this section will start with some reflections on the challenges encountered during the programme design stage.
8.4.1 The Mixed Methods with Quality Service Circle’s implementation challenges
The focus on training and supporting the CHMVGs was based on NMJD’s original proposal to Christian Aid in 2012, in which NMJD proposed to set up community- based health monitoring groups. By September 2012, around the time NMJD’s proposal had received funding from Christian Aid and as the first project interventions were about to get underway, it transpired that the setting up of community-based health monitoring groups had already commenced on a national scale.72 In July 2012
72 The reason why neither Christian Aid nor NMJD staff was aware of this was due to the fact that both agencies had little previous experience in working in the health sector. While the deployment of Health for All Coalition monitors must have been extensively covered in the media, it was clear that the CASL and NMJD staff who were dealing with the design and early stage implementation of the programme simply did not internalise the consequences that HFAC’s newly introduced national monitoring drive would have on their programme. 272 the Government of Sierra Leone, together with the donors of the Free Healthcare
Initiative, awarded the national NGO Health for All Coalition the contract to ‘resurrect or establish community-based health monitoring groups’ under the new name ‘Facility
Management Committees’ or FMCs.73 Health for All Coalition devised a strict formula for FMC membership: the five members were to include three women and two men, with a chairlady as its leader. Within months, FMCs were formed in the vicinity of every one of the country’s 1000+ Primary Healthcare Units. Health for All Coalition provided one day of training for all FMC chairladies, and with external funding, the government provided each FMC chairlady with a mobile phone to call a free phone number to report drug stock-outs or any wrongdoings.
In September 2012, during my exploratory study visit to Kono facilitated by NMJD, I attended a meeting between NMJD and Health for All Coalition staff. It did not take long for NMJD to realise that the intervention they were about to implement would duplicate what was undertaken by Health for All Coalition. This led to several discussions with NMJD staff about redrafting its proposal. NMJD had two staff members in Kono for the ‘Community Health Monitoring for Accountable Health
Services in Kono’. One had previously worked with NMJD but had just returned from a two-year overseas study break, while the other was newly recruited. Neither had any work experience in the area of accountability or health, so they looked to me for guidance with regards to the re-drafting of their proposal. After some hesitation, in which I considered my supposed impartiality as a researcher, I pointed out that NMJD had previously, and successfully, used the Quality Service Circle method, and that this might be a good starting point. I had read all the documentation Christian Aid had
73 Where those groups existed, they were usually known as village health committees. Many of the international NGOs that had contributed to the post-war reconstruction of health facilities throughout Sierra Leone had put village health committees in place. 273 provided to me about NMJD in preparation for my visit. I suggested that the organisation could ask NMJD colleagues, who had been involved in the QSC implementation in the past, for help with the possible integration of this method into the new proposal. In the weeks following my field visit, NMJD decided to cancel the idea of setting up additional monitoring structures, and changed the focus of its intervention to strengthening the FMCs in ten target clinics. NMJD also chose to implement a series of additional components to improve the relationship between citizens and health service providers, and included plans to hold a series of QSC meetings.
The Quality Service Circle method closely resembled the Community Monitoring method discussed in chapter five. Its objective was to bring health workers and community representatives together to discuss health service delivery problems experienced by the community. Both methods had few fixed rules, so each implementation could be adjusted to the needs of the community, the implementing agency and the external environment. NMJD’s QSC meetings gathered relatively small groups of community representatives74, compared to the large-scale meetings that were held for the Community Monitoring intervention explored in chapter five. NMJD documentation shows that the problems discussed during the interface meetings were based on a survey that was conducted in the communities where the clinics were targeted. NMJD’s reports provided narrative accounts of the QSC meetings (targeting all ten clinics in June and July 2013) that show that in each community, five pregnant women and five lactating mothers were asked to complete a written seven-question
74 There was no minimum or maximum number of participants in the programme guidance, but NMJD staff told me that between 30-40 people usually attended the QSC meetings (KI79). 274 survey, which provided the basis for the discussions around the ‘problems’ the community faced regarding their access to healthcare.
NMJD staff admitted that the collection of the survey data from illiterate community members was a challenge. Given that Sierra Leone has a 41% adult literacy rate nationwide (which is lower among women than men, and much lower overall in rural areas), it is likely that few, if any, of the women would have been able to complete the survey without having the questions read to them and the answers noted down by the enumerator - which compromised the anonymity of the interviewees. Surprisingly, the
QSC discussions with health service providers appear to have been based on all responses taken together, rather than clinic-specific problems. The report about the
QSC meetings shows that the situation the NMJD team encountered was as follows:75
In 10 out of 10 clinics, women pay for deliveries (in 1 case the fee was agreed by traditional authorities) In 7 out of 10 clinics, women pay for care for children under five In 4 out of 10 clinics, the health worker(s) do(es) not reside in the community (thus resulting in irregular clinic opening hours and a lack of emergency night- time and weekend coverage)
In a number of locations, issues were raised regarding the health seeking behaviour of the community, for example, women did not attend enough ante-natal check-ups, children were not brought to the clinic for vaccinations, and people consulted herbalists and took alternative medication. In seven out of ten clinics the relationship between community and nurse was described as ‘not cordial’. This could be interpreted in a number of ways, it sometimes reflected the nurses’ complaints that community members were not supportive with gifts of food, and that the community members did
75 This data was based on a very small sample, 10 questionnaires per location. It was presented by location, but in-depth analysis of the problems (and reasons for them) was limited. 275 not help the nurse clean the clinic and its surroundings. In one case, it was mentioned that members of the community did not come to the clinic promptly when their children were sick, and did not bring children for vaccinations when required.
Rather than drawing up individual ‘action plans’ between health workers and communities during the QSC meetings, NMJD’s reports show that verbally agreed
‘actions points’ were noted down after the meetings. However, these action point lists were not available when I asked for them, and they do not seem to have been shared with the CHMVGs or members of the community to refer to at a later stage. The original documents were not retained either. Instead, a single report was written that outlined what general solutions were found for some of the recurring problems (NMJD
2013c).
As a response to the problem of “Payment for drugs/treatment/service” health workers promised to: “Communicate drugs under FHC to communities and those to be paid for on cost recovery scheme”, “Display FHC drugs list” and “Inform CHMVGs on a daily basis about drugs in clinic”. The community, for its part, undertook to “Demonstrate willingness to pay for all drugs out of FHC package according to government policy” and “CHMVGs to organize meetings and inform community people about the supply of drugs in the clinic”. The issue of paying for deliveries appears not to have been tackled at all, as these payments are usually made to the Traditional Birth Attendants who had started ‘volunteering’ in health centres after the introduction of the Free
Healthcare Policy. In most cases, the issue of health workers not staying at the clinic but only travelling to the community for a few days per week was met with similarly lacklustre solutions: “Health personnel explain to CHMVGs the reasons for leaving the
276 clinic”, “Reduce private travelling” and “DHMT to increase staff to at least two in any health clinic” (NMJD 2013b, 2013c).
The NMJD Quality Service Circle meetings appear to have been a one-off intervention, with few commitments written down and no agreed upon verification methods to check if anybody lived up to their promises. This was unlike other social accountability interventions in which compacts or joint action plans are usually agreed in the first meeting and this meeting is then followed up by either a second interface meeting or a monitoring plan and a list of indicators to measure if common goals were achieved (NMJD 2013a). The QSC methodology was also at odds with NMJD’s previous implementation of the QSC method, and it appears as if the colleagues who implemented this previous intervention were never consulted. I assumed that the
CHMVGs were expected to follow up on the service improvements and behaviour changes promised during subsequent meetings with the community, but this is not explicitly stated anywhere within the programme documentation. The interviews with
CHMVG members, summarised in section 8.3.3, will confirm that the QSC action points were not discussed by the CHMVGs.
By relying heavily on members of the local community for the monitoring of the healthcare staff on which they themselves also rely for their healthcare needs, the
NMJD project design always carried a serious risk that the quality of the programme would be undermined by the lack of capacity or commitment from the CHMVGs.
NMJD’s programme was slow to start. In May 2013, by the time NMJD staff were ready to implement its revised programme and start to engage with members of the
Facility Management Committees, many of the original groups formed by Health for
All Coalition in July 2012 were often no longer active (KI79). Each FMC chairlady
277 had received only a single day of training (KI002) and because there was no follow up from the agency that had set up the groups, FMC members had stopped visiting their local clinic regularly. Despite receiving additional training from NMJD and a monthly stipend for its members, the evidence of active engagement of the CHMVGs with the health workers and the communities was mixed. In two communities the groups appeared very active, but elsewhere the CHMVGs barely engaged with the health workers or the community. It seems as if NMJD staff struggled to motivate the less interested groups, while focusing on the more active groups and those that were within striking distance from Koidu town, where the two field staff were based.
8.4.2 Findings – from the health workers’ perspective
There were only five interviews with the health workers in charge of the clinics targeted by NMJD’s Mixed Methods, since four of the health workers I had planned to interview were unavailable. The absence of the four health workers was regrettable, but occurred at a time when the research visit could no longer be rescheduled. The research went ahead: I visited nine out of NMJD’s ten target clinics, carried out nine health user focus group discussions and nine CHMVG interviews.
The absence of these health workers reflected badly on NMJD’s local staff: it was clear that they had not had any communication with the health workers of their ten target clinics in advance of our arrival (a research visit planned several months in advance by Christian Aid Ireland, Christian Aid staff in Freetown and NMJD headquarter staff). It transpired that the NMJD staff mainly communicated with the
CHMVG representatives, who were clearly also unaware that the health worker in charge would be absent. The TBAs we met at the first clinic explained that the ‘in 278 charge’ had gone to Koidu for a workshop. This did not reflect well on the supposed good relations (and regular communication) the CHMVGs were supposed to be cultivating through the NMJD project. Finally, after we had visited several clinics where the ‘health workers in charge’ were absent, we met one health worker in charge, who had just returned from the workshop explaining that it had been cancelled. This particular health worker had travelled all the way to Koidu for the workshop, found it was cancelled, decided to spend a day taking care of personal matters, and returned to his clinic thereafter. It therefore transpired that all of the other absent heads of health centres had also found the workshop cancelled, but were simply taking a few days off before coming back to work.
The five heads of health centres I did manage to interview discussed a wide range of issues. One of the most pressing ones was the lack of funds for volunteers at the clinic and the problem of trained staff not being ‘on payroll’ and therefore not receiving a salary. In one case the health worker in-charge (HW84) himself was not on payroll, he explained: “I am the in-charge but I am not on payroll. It's very pathetic. I'm just coping. I am just from the classroom, where I've exhausted all my resources, I had hoped to upkeep my financial status, but to no avail.” When asked how long ago he finished his studies, he explained: “I went to an upgrading course in 2012, I finished nine months ago and started working in 2013. It is very frustrating, I have my [national security] number, my pincode, my verification, everything has been done to complete the paperwork and put me on the payroll but something must have gone wrong in main admin system, I don't know."
Another health worker (HW93) in charge revealed that he was ‘not on payroll’ for most of the decade before the Free Healthcare Policy. This illustrates how
279 dysfunctional the health system was before the introduction of the FHCI. This particular ‘health worker in charge’, lived in an extremely remote location. He explained:
I am a state-enrolled nurse, working in this community since 1984 after I finished training at Nixon Hospital, Segbwema. By then, in 1984, there was not one qualified health worker in whole chiefdom. I came here and started up my own clinic. Dr. Buna, based in Koidu, supplied me with medicine so I could treat people. People came from 15 miles off, even from Kenema district. After the war a clinic was constructed here in this village, in 2002/3, and I started working here again. I transferred to work at another clinic between 2005-2007 but I have been back working here since 2007. I was first put on government payroll in 2010.
The same health worker (HW93) highlighted further challenges related to the remote location and many clinics’ lack of support from the District Health Management:
We face many constraints: the road network is poor, the drugs delivery truck can’t always reach us, so they leave our medical supplies at another clinic nearby. Our fridge has not worked since 2007, so we have no place to store vaccines. DHMT once sent somebody who tried repairing it, but it didn't work. We walk on foot to collect vaccines at the next clinic.
The story was more complicated than that: during our interview, conducted at midday, the health worker in charge was clearly intoxicated. Half of the interview focused on money and his need for additional allowances. He showed off a new motorbike which had recently been donated by the international NGO World Vision, but complained that it did not come with a fuel allowance. Given that the motorbike seemed to have remained unused since its arrival two months previously, it made me wonder if his demand for a motorbike was motivated by the desire to obtain a fuel allowance from the same agency rather than the need for transport. And considering the fact that the fridge had been out of action since 2007, it was surprising that this item was not considered a higher order need than the motorbike.
280
Problems with broken fridges and the need to travel to nearby clinics to collect vaccines were echoed by another health worker (HW88) who calculated that much of the discretionary clinic budget was spent on collecting vaccines every month:
[…] the fridge is a problem, it is not working: pregnant women and also children under five, they need vaccinations but they don't get them on time. We have to send our vaccinator to Koidu Government Hospital to collect the vaccines. At the end of the vaccination day we bring the remaining vaccine stock to the nearby clinic. It cost Le 24,000 [US$ 5.60] for a return trip to Koidu and Le 14,000 [US$ 3.26] for a return trip to where vaccine is stored, so it costs Le 38,000 [US$ 8. 86] every time we have a vaccination day. Because of the broken fridge there's only one vaccination day per month. If the fridge was working, we could do it weekly.
Conversations with health workers focused on their engagement with NMJD’s
Community Health Monitoring Volunteer Groups. The responses were mixed, one health worker (HW84) in charge explained:
The health committee [CHMVG] is dormant. Dormant to the clinic workers at least, because we expected them to be around during activities, vaccinations, interviewing people, asking patients ‘what is your problem, what is your complaint?’ The first time I called a meeting with them when we first arrived, I wanted to know what they were doing. Unless you call them, they don't come. Monthly meetings with clinic staff? No, not at all, we held one, but after that, never again! We call them when the drugs arrive, they come, even the town chief […] they check the invoice, let me show you […]. Look, all is ticked off by the chief, signed by health committee chairlady. Unless you call them, they don't come.
At a different location, the CHMVG appeared to be more active, especially when it came to working with the community. One health worker (HW88) remarked: “Since the CHMVG started, I can see a bigger flow of patients in the clinic, they have sensitised people about the free care, so more people are coming now. I am also happy for the waiting house [for pregnant women] that they are constructing. I will be looking forward to move into it - in this clinic I only have one room, there is no parlour [front room] for me.”
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On the impact of the Quality Service Circle meeting, several health workers reacted positively, one health worker in particular (HW104) was full of praise: “This meeting was very useful; it brought peace between the staff, the health committee and the community.” When asked what was discussed:
We discussed the PBF payments, also that we have to work with the health committee, we should not take them as our enemy. We had to explain to them about PBF. We also talked about having the TBAs, who are not on payroll and we have to share some of PBF with them. We, the nurses, should learn how to talk to the patients in a better way, so that people feel happy to come to the clinic. After this meeting only good things changed into our lives. We now use better language to talk to the patients.
This particular clinic is NMJD’s success story: the Quality Service Circle and several subsequent meetings really did transform the relationship between the previously unfriendly health worker and the community. When the health worker was diagnosed with a condition that limited her ability to walk long distances, it was the community and the CHMVG who petitioned the DHMT to be able to keep the nurse and to have a second nurse allocated to the clinic, which duly happened. The clinic is now busy and facility births have been going up, the nurse attested (HW104):
Before the quality circle meeting we were getting five or six deliveries per month, but but since the new staff member arrived we get 10 regularly. Last month we had ten babies. We are close to many communities, some people heard about the extra nurse, so they come. The TBAs also bring women. We have rota so there is always somebody here.
Another health worker (HW107) also stated that the Quality Service Circle meeting improved her relationship with the community:
The [CHMVG] went for training and they held a big meeting. After that meeting everything changed. The [CHMVG] sensitised their people and the people are coming now. I am happy, I don't like to come to clinic and meet no patients. Before the meeting, the people didn't come to clinic. After the meeting they started coming, look […health worker shows patient attendance charts]. 282
8.4.2 Findings – from the healthcare users’ perspective
The focus group discussions in the area where the MM/QSC intervention was implemented, were often dominated by the problem of charging for free healthcare. As can be seen in figure 12, the problem of charging came up in eight out of nine focus group discussions. Other problems the women discussed affected their ability to access healthcare: there were several locations where the health workers were not staying in the community (which had been highlighted in NMJD’s pre-intervention survey, and they had clearly been unable to change this problem), thus limiting the opening hours and emergency care available at the clinic. While some of the charging for care concerned payments to the TBA for assisting during delivery, the magnitude of the cost was such that it created problems for women who were pregnant, including stress about how they might gather the required amount of money.
Figure 12: Illustration of incidence of alleged charging for free care, raised during FGDs
10 9 8 7 6 5
4 3 No charges for free care 2
clinic 1 mentioned 0 Problem with charges for free care discussed Number of FGDs aboutnearby
Overall, the issue of charging was quite serious in this cluster of FGDs. More surprisingly, it was clear that this was a shock to the NMJD staff who accompanied me during the field visits. In total, I visited nine out of the ten clinics NMJD targeted with their intervention, and I encountered only one clinic where there was no discussion 283 about fees, and one clinic where the main problem was the hefty delivery fee for the
TBAs, which the community agreed to pay.
It has to be borne in mind that reducing charges for free care was not the only indicator for improvements in healthcare delivery.76 Despite the fact that charging for ‘free care’ seems to have continued in areas where the NMJD intervention took place, there were some positive changes in health worker behaviour in locations where NMJD worked.
The most significant case was in a remote community which appeared to have a serious problem with alcohol (local brew) consumption. I encountered a significant number of villagers who were gathered at one or two brewing house, all with big gourds of locally produced alcoholic drinks (including a woman who was eight months pregnant), and it was also noticeable in the health worker in charge, who was seriously intoxicated when we met him at his clinic at midday. During the FGDs the women I spoke to explained that, despite the free healthcare initiative which was introduced in
April 2010, the members of the community had continued paying for healthcare until
NMJD trained the CHMVG and the group started telling the community about the entitlement to free care.77 One of the women admitted hearing something about free care on the radio before that, but she had assumed that “was something that happened in Freetown”. The group (FGD92) explained: “The CHMVG went to Koidu for training and when they returned, they called a big meeting, explaining all about the free care. After that, the nurse stopped charging us for the treatment of children and pregnant women.”
76 In fact, the reduction of charges was only one of my personal indicators, based on my assumptions of what ‘improved accountability’ in the health sector should look like. Only the PM&E intervention had created clear targets for improved accountability, based on the assumption that clinic should fully implement the free healthcare policies. 77 Entitlements for free care extend to pregnant women, lactating mothers and children under five. 284
During the discussion it transpired that the care they now receive is not entirely free, but money is no longer required, as the community has switched to informally supporting the second health worker, who does all the work at the clinic: “We help her when we can, some bring firewood, some do gardening or fetch water for her, some do her washing […]. We all want to help her, because she tries very hard” (FGD92).
While we discussed the details of the QSC meeting that brought change to this community, the NMJD team admitted that they had not attended this ‘big meeting’; the
NMJD staff had only collected the survey data and organised a QSC training day for all of the CHMVGs. It transpired that the NMJD staff had let a number of CHMVG groups take care of the community-health worker interface meetings themselves. I double checked this with one of the NMJD staff members who accompanied me and she admitted that “it had been impossible for me to be there, but we did arrange for a member of the DHMT to attend.” This admission made me doubt whether some of the
QSC meetings had actually happened at all. Reviewing the interview data, it seems as if two QSC meetings may have never taken place: At one location, the women
(FGD97) I interviewed could not recall any meetings involving the community,
CHMVG and health workers, while at a different clinic the health worker (HW84) in charge confirmed that he had not participated in any QSC meeting.
At the five locations where the health workers were absent, regular absenteeism seemed as common among the healthcare staff as charging for free care: the women talked openly about the problems during the focus group discussions. In one location
(FGD95), the opening question “How can you describe the Free Healthcare that you are receiving?” was met with a prolonged silence in which the women were clearly unable to think of anything positive to say about the supposed free care. The women
285 went on to explain how the health worker and the TBAs charge an extortionate amount for assisting women during delivery: “the sooner you are pregnant you start thinking about how to raise that money, because you are not even thinking about delivering for free. She charges for gloves, Le 5,000 [US$ 1.15], you bring six soaps, they are Le
2,500 [US$ 0.60] each, but if you buy them on a market day you will pay Le 2,000
[US$ 0.46] per soap, plus the fee of Le 30,000 [US$ 7.00].” The TBAs, who are only supposed to assist the health workers during delivery, are usually the only ‘skilled’ personnel available when a woman gives birth at the clinic. When asked if the
CHMVG’s interventions have led to any changes in healthcare delivery, the women explained: “Well, the nurse has reduced the price of the treatment for the under fives and the lactating mothers, if there are FHC drugs. If they have run out, she shows you the cost recovery price list and you pay.” It seems as if the women regularly pay for the drugs that they need, because the FHC supplies are often out of stock. I asked how they know whether the nurse tells the truth? The women admitted: “Well, we don't know, we are not educated, so we just don't know. When they deliver the free healthcare medicine the nurse will call the village elders and the CHMVG to show them the drugs, but after that the nurse packs all of the meds into the clinic and nobody but her knows when the drugs are finished.”
It is clear that many of the women remained uncertain about what should be free and what should be paid for. In yet another focus group discussion (FGD81), women explained how they paid Le 7,000 for the antenatal card “for the printing costs”, but subsequent antenatal check-ups were free. The same women also paid Le 1,000 [US$
0.23] each time they came for vaccinations. For most other visits to the clinics the women paid between Le 1,000 [US$ 0.23] and Le 2,000 [US$ 0.46] each time.
286
Probably the saddest case that was encountered in Kono was at another remote location where the nurse was absent. The women in the FGD (FGD97) recounted the death of a child from cholera the previous month78: “There was an outbreak of vomiting and diarrhoea because there is no safe drinking water here, there was no medicine at that time, so one of the children in the village died.” When I asked the group to clarify what they meant by “no medicine”, the women explained: “The former nurse had already left for training, so she was not there. The new nurse came and she found no drugs here at all, no FHC drug, no cost recovery, nothing!” I enquired if they thought the last nurse may have taken or sold all the medicines in the clinic, as it would have been impossible to have used every single drug by the end of her assignment to their clinic.
The women suggested they thought the same, and had asked the new nurse, but she did not seem interested: “The new nurse simply said she didn't know, she found nothing in this clinic at all, she didn't know why, so she could not offer any treatment.” This anecdote is a clear illustration of the tragic cost of poor accountability in the health sector in Sierra Leone.
8.4.3 Findings – from the healthcare monitors’ perspective
NMJD’s Mixed Methods programme was the only one that focused strongly on working with community-based groups for the purpose of monitoring the delivery of the local health services. As I alluded to earlier, such groups, commonly known as
FMCs, had been established at health centres country-wide in 2012. NMJD decided to work with ten such groups, Community Health Monitoring Volunteer Groups
(CHMVGs) to enhance their effectiveness. The CHMVGs’ level of engagement with
78 A cholera outbreak in that community was later confirmed by the DHMT. 287 the programme, with the community and with the healthcare staff was patchy at best.
There appears to have been a number of reasons for this:
Absence of training
The results from the interviews with nine groups of CHMVG members presented in this section, show that training the CHMVGs was badly needed, as most of the groups had received little training, and were set up (as FMCs) without any ongoing support or even contact with either the local District Health Management Team or the NGO that set up the groups. Most group members talked about the NMJD-supported monitoring activities as being the first they carried out, despite the fact that the CHMVGs were made up of the five members of the pre-existing FMCs, who had been mandated to
‘monitor’ the healthcare delivery since the summer of 2012. NMJD started providing training to the CHMVG members in 2013, equipping them with basic knowledge about the free healthcare policy and the entitlements to free care for pregnant women, lactating mothers and children under five. Most groups commenced their activities in
June 2013, as one group (CHMVG91) recalled:
When the FMC was established by Health for All Coalition, the in-charge [of the health centre] simply didn't accept us, so there was a problem between the FMC and the in-charge. When NMJD started giving workshop and training, the relationship with the in-charge improved. When we go to the in-charge he will take the CHMVG more seriously.
In addition to providing training, NMJD also stipulated that the CHMVG members collect monthly clinic-specific data, such as the numbers of patients, vaccinations and facility deliveries, which CHMVG members are requested to include in their monthly report. The reporting requirements ensures that at least one member of the CHMVG visits the clinic every month. Ideally the CHMVG-health worker relationship would be 288 about more than a monthly data collecting visit, but the reporting ensured there was a minimum level of contact. Some CHMVGs used the need to report as leverage over the health workers (CHMVG91):
We write a monthly report and send it to NMJD. When the Quality Service Circle meeting was held in this community, NMJD brought somebody from the District Health Management Team with them, and this seems to have scared the health worker. Maybe he assumed the event was held because of what CHMVH wrote in the monthly report. After that the in-charge took the group more seriously.
NMJD’s Mixed Methods intervention also included training in ‘budget tracking’ for the CHMVGs. The training was solely focused on the Performance Based Finance
(PBF) payments that were allocated to clinics. According to the PBF guidelines, the facility management committees are supposed to be engaged in the planning79 of the expenditure of the 40% share of PBF funds which each clinic receives - the remaining
60% is supposed to be shared among staff members according to their official grade
(Ministry of Health and Sanitation, Sierra Leone 2010). The interviews with the
CHMVGs revealed that none of the nine groups I talked to had ever been fully engaged in joint planning and budgeting with the health worker(s) on how to spend the quarterly PBF funds, neither as members of the FMC nor as CHMVGs. Despite the fact that the CHMVG members received training and encouragement by NMJD to engage with the health workers on this topic, very few groups reported positive results.
One group (CHMVG 105) explained that they knew what the last disbursement of PBF funds were spent on, but the health worker had not shown the group the receipts for the purchases, despite them asking for the receipts. Another group (CHMVG96) explained
79 Interestingly enough the guidelines of the involvement of the FMCs were not contained in the MoHS’s 2010-2015 Basic Package of Essential Health Services, the Free Healthcare Policy, or in the MoHS’s 2010 Performance Based Finance Manual, but these guidelines were commonly known. The MoHS’s 2015-2020 Basic Package of Essential Health Services does stipulate that: “Communities can be involved in the health system through management structures such as Facility Management Committees (FMCs), which work together with PHU staff to develop the facility investment plan for each PHU, agree on the use of PBF funds”, p 27. 289 that it had agreed with the health workers that they would jointly plan how to spend the
40% of PBF, but when the money came, the nurses told the group they were unwilling to disclose how much PBF money the clinic had received, so they could not be part of planning how to spend the money. Seven out of the nine groups were simply shut out of any engagement on PBF discussions, one group reported (CHMVG103) being told that “NMJD does not pay the health workers’ salaries” in other words: we are not accountable to NMJD, so you should not expect our engagement on that front.
Changing behaviour
Several groups reported significant changes in the health workers’ behaviour since the
Mixed Methods intervention. In some cases, these statements are confirmed by what the women said during the focus group discussions in the same area, as one group
(CHMVG96) explained:
The people say ‘Thank God for the CHMVG’ because they used to pay a lot of money, but now that has reduced. Before we became active, there were a lot of problems in the clinic, when the free healthcare drugs were delivered to the clinic, nobody was called to witness! Now the group [CHMVG] and the town chief are called each time. There was a problem with the attitude of the nurse: I live far away across river and when we made big effort to come to the clinic, she could just turn you away. Now she doesn't do that anymore even at night you can come. The nurse never used to stay here, she would come only two or three nights and she would go to Koidu.
Despite several examples of success achieved by the CHMVG, my overall impression was that the impact of the CHMVGs was mixed. In a number of locations the groups were active and achieved great change in the behaviour of the health workers they targeted. In two places the pressure from the CHMVGs and the community led to a significant reduction of the charges levied. In several additional locations, the intervention led to other behavioural improvements among the health workers, such as
290 longer clinic opening hours, friendlier attitude towards patients, better, more frequent, scheduling of vaccination days and outreach programmes. These achievements were often small shifts in the right direction: in a number of cases outright charging was replaced by agreed service charges which were often introduced to compensate the unpaid staff who worked at the clinic. While this did not make the health services free, the set charges were usually a reduction compared to previous practices and they were predictable, which was important. There was one exception, in one clinic, according to the focus group discussants, the TBAs and the health workers colluded by heaping additional charges onto the TBA’s set delivery fee, making it as costly as before the
FHCI to deliver a baby in the clinic (FGD95).
Engagement of the CHMVGs
While some of the more successful CHMVGs achieved mixed, but largely positive results, there were a number of CHMVGs (four or five out of nine – it was hard to judge) that appeared reluctant to engage with the clinic staff. These groups primarily focused on changing the health seeking behaviour of the community. The majority of these groups listed their primary activities as being: ‘sensitising the community about the free healthcare entitlements of pregnant, lactating women and children under five’; reminding the women of the community to ensure their children are fully vaccinated; telling pregnant women they should not give birth at home; and encouraging the community to help clean the clinic’s surroundings. During a number of CHMVG interviews, the dominance of the men in the group clearly posed a problem: when I asked one group (CHMVG96) if the women in the community ever complained to the
CHMVG about being charged for giving birth at the clinic, the self-appointed
291 spokesman quickly answered “no, nobody has ever complained to me”. When his female colleagues got the opportunity, they gave all the details about the complaints they had received. Other groups (CHMVGs 82, 98 and 105) too explained that they did not actively seek feedback from women who attended the clinic, but, as one spokesman explained: “we have told people to come to them if problems were encountered” and they therefore presumed that “no complaints meant no problems”
(CHMVG 105).
Information weaknesses
One of the design challenges the ‘mixed methods’ intervention brought with it, was the overload of activities that the CHMVG members were expected to engage in. It was clear from the interviews that the members had so many things to do that each separate component became a ‘tick box’ exercise, which focused on the action, rather than the information gleaned from it. The data collecting component was often reduced to sending the secretary of each CHMVGs to the health worker once a month to copy the clinic statistics on out-patient numbers, facility births, etc. When asked what trends the groups saw from the data they had gathered, it transpired that only one out of the nine groups kept copies of the statistics they passed on to NMJD. The majority responded that facility births had gone up without having ever looked at the data they collected.
Lack of quality in programme delivery
The NMJD programme contained several other additional activities which were probably well intended as programme components, but were badly executed and
292 distracted from the core activities. Firstly, there were the radio listening groups: NMJD had teamed up with several other health advocacy groups in Kono District and they jointly produced an hourly programme that was aired twice a month. The radio listening groups were set up to further reinforce information about the free healthcare and spread general health messages. Providing radios and getting the CHMVG to set up groups that congregate at set times outside the health facility, was intended to attract the community to the health centre where people could bond with the health workers while listening to the programme. Unfortunately the radios that NMJD bought were of such bad quality that the majority never worked or were beyond repair within weeks.
Community contributions
The other component that seemed to be distracting from the accountability focus was the ‘community contribution’ initiative. This was yet another part of the programme that was added at a later stage. The NMJD Kono project leader explained that this component was added in response to demands from health workers who felt that they were gaining very little from the intervention. The idea was that the CHMVG would mobilise the community to donate funds or labour to ‘do something’ for the health workers in the target community. This aspect was also badly implemented, the building blocks the community made for the construction of staff houses or maternal waiting rooms were completed just before the rains and because they were left unprotected, most of them were rendered unusable. Few of the planned construction projects were ever finished. In three locations the money raised went towards buying a generator for the clinic. While the generator purchases had the advantage of having an
293 immediate impact and probably made the rural clinics a better place to work, it was obvious that the NMJD staff had left key questions regarding the fuel for the generator unaddressed. When I asked, neither the health workers nor the NMJD staff was able to explain how fuel for the generator would be bought in the future; which funds could be used to buy it and if the fuel bought with clinic funds could be used to provide electricity for the comfort of the health workers or only for healthcare purposes.
Paying for healthcare
One noticeable aspect of the Mixed Methods approach was the fact that it seems to have led to more ‘agreed charges’. During most of the CHMVG interviews or health user FGDs the phenomenon of healthcare users and health workers agreeing on set fees for certain services was highlighted. It seems likely that the CHMVG played a role in bringing the needs of both the community and the health workers together and this led to the realisation that the free healthcare was not working for either party. It did not work for health workers because it deprived the health facilities of cash with which regular but unpaid staff such as vaccinators, TBAs, cleaners, etc. could be paid, and it did not work for healthcare users because under the free healthcare initiative, unpredictable charging continued. Several healthcare users expressed the opinion that lesser but predictable charges were preferable to unpredictable ones. One CHMVG member (CHMVG105) explained:
This was the scenario: when NMJD gave us training, we started going round to explain to everybody about the free healthcare. The people were not knowledgeable about the free healthcare, so they were still paying. After NMJD's intervention, people started refusing to pay charges that the health workers asked for, because they knew they were entitled to free care. This meant that the TBAs could no longer charge for delivering babies at the clinic, so they stopped coming to the clinic. But this was a problem too, because the nurse is on her own, she can't be here day and night, she has to travel to 294
Koidu for workshops, to hand in the monthly report, etc., so she needs the TBAs to cover for her. This led to us and the traditional authorities getting involved and that is how we got the ‘gentleman’s agreement’ to pay the TBAs Le 1,000 [US$ 0.23] for growth monitoring and Le 30,000 [US$ 7.00] for deliveries.
While the Mixed Methods programme, with all its inductively added components, was generally the least well designed80, there were definitely some interesting positives about this intervention. One of the CHMVG members (CHMVG103) added towards the end of our interview that the CHMVG had brought the community closer:
“Recently one woman had a complicated birth and an ambulance had to take her to
Koidu hospital. I accompanied the woman, stayed with her and we returned together after the baby was born. She was not my relative. In the past people were less together, now we collaborate more.”
8.5 Analysis
For the analysis section, I return to the analytical framework introduced in chapter three, to assess NMJD’s Mixed Methods intervention on the four key components of a social accountability intervention: i) redressing information imbalance, ii) citizen participation, iii) power and political awareness, and iv) sustainable staff motivation.
8.5.1 Redressing information imbalance
NMJD’s mixed methods intervention had a multi-faceted ‘redressing information imbalances’ component, which was predominantly of the ‘info in’ variety. It was
80 I wonder what components were taken out when others were added in- to balance the budget. I suspect that the planned follow up round of QSC was axed in favour of the community construction component. 295 operationalised in several ways. During the programme’s initial period, the NMJD team had played a DVD which provided the target communities with information about the FHCI. This component, and even the DVD itself, was borrowed from SEND
Foundation, which also hosted NMJD staff during a learning exchange visit to
Kailahun.81 There is little information regarding how often the DVD was shown, whether it was shown in the villages where the ten target clinics were located or beyond, and if there were dialogue sessions afterwards. There were no references made to the DVD showing events during interviews and focus groups discussions, except by one NMJD staff, who assured me that multiple viewings took place in each target area.
The second information component was the training NMJD provided for the
CHMVGs. The training focused on the free healthcare entitlements and the information which CHMVGs should pass on during their sensitisation activities within the communities. Among the sensitisation messages that CHMVG members were trained to deliver to the community was the notion that people should ‘claim’ their health entitlements and that the health facility was there ‘for the community’. These were positive, aspirational statements of the kind that were rarely heard in post-war
Sierra Leone, where citizens expect their government to provide little for them. It is likely that such catch phrases helped the community increase their sense of citizenship, but in cases where women knew their entitlements but were too afraid to stand up to a powerful health worker demanding cash, the same words may have rung hollow.
Nevertheless, the very basic intervention of providing people with clear information about their entitlements was clearly a useful one; several times healthcare users and
CHMVGs recounted “that regular charging for free healthcare reduced once the
81 Both agencies were partner agencies of Christian Aid and implemented programmes that had a very similar objective. Christian Aid made funds available for the exchange visit to ensure that NMJD could learn from the larger programme implemented by the more experienced agency SEND. 296 community understood what their FHC entitlements were”. However, given the fact that the programme targeted only ten clinics and its core activity was improving accountability, it is surprising that this programme did not achieve a 100% success rate
(in terms of hearing from healthcare users that they have been well informed about the free healthcare). It suggests that the additional interventions distracted from the programme’s main objective and its well-designed information component suffered as a result.
Although I believe that the MM/QSC’s information component was well-designed and suited to the operational environment, there is a caveat, which also applied to the
PM&E method’s ‘info in’ component. It has to be remembered that when Health for
All Coalition was mandated to set up Facility Management Committees throughout
Sierra Leone, it too had the task of putting community based monitoring groups in place who would be trained to disseminate information about people’s health rights.
NMJD’s sensitisation campaign was implemented less than a year after the work of
Health for All Coalition. Had the latter carried out its mandate properly, NMJD would have done nothing but duplicate their work. As it turned out, NMJD’s intervention was much needed, not by their design, but because of the other organisations’ failure.
NMJD’s information component targeted primarily the CHMVG members who were supposed to monitor the delivery of the free healthcare. In several locations, NMJD’s information component appears to have had a strong power-redressing affect. In some locations the CHMVG was well organised, and NMJD ensured that a member of the
DHMT came to attend an interface meeting, several pro-accountability factors appeared to reinforce themselves. The community members were equipped with power-redressing information; an opportunity was created for citizens to confront service providers in a safe environment; well-trained CHMVG members, who knew 297 they had the right to hold health workers accountable on behalf of citizens were present; and a member of the DHMT was there, which further leveraged the power of the citizens and the CHMVG.
As noted in chapter 3, several of the analytical framework components interact with one another and this is a clear example in which several components can be seen as positively reinforcing. Whether the presence of several components working together creates a greater chance of an intervention succeeding is something that will be looked at in greater detail in chapter nine.
8.5.2 Citizen participation
The design of NMJD’s mixed methods intervention had by far the strongest focus on citizen engagement. By anchoring the implementation of the programme to the
Community Health Monitoring Volunteer Group, the intervention dealt primarily with members of the community. Whether it achieved broad-based participation in practice was less obvious. Whereas the Facility Management Committee rules stipulated that the chair person had to be a woman, NMJD made its focal person the secretary of the group, usually a man. NMJD did not question the make-up of the existing groups, which were composed in haste, had no members elected by the community, and did not take power imbalances into account. It was clear that in most cases, the FMC members of the CHMVGs were ‘senior members’ of the community, who would naturally have put themselves forward as representatives of the community. Such
‘natural representatives’ are often privileged members of the community, maybe minor chiefs or chief’s relatives, who in Sierra Leone society often feel entitled to take on a representative role and receive the stipend that comes with it (Richards et al 2004). It
298 was striking how little women’s voices were heard throughout the CHMVG interviews. The voices of women who fall into the free healthcare category (i.e. a woman who is pregnant, lactating or the mother of a child under five) were heard even less, although they should have been an obvious choice as monitors of a service that was specifically designed for them. In conclusion, the way the CHMVGs were composed meant that the intervention did not achieve broad-based participation, nor did it prioritise working with members of the community who would have been most logical community representatives for a health accountability intervention.
As noted in the CHMVG interview data, in many cases the CHMVG members appear to have focused on telling the community about their entitlements and about the health seeking behaviour they should adopt, while shying away from collecting information from the community regarding their healthcare experiences, or confronting health workers who did not act accountably. It appears to have been so because CHMVG members were unwilling to end up in conflict with the health workers - which could result in a health workers denying individual members health care; walking out of their post or being removed by the health authorities. However, NMJD should have tried harder to ensure that the CHMVG engaged in regular and robust dialogue with the health workers in their area. By not paying attention to the quality of CHMVG - health worker engagement, NMJD failed to ensure that some of the community groups lived up to their responsibility as advocates for the women and children of the community.
8.5.3. Power and political awareness
The NMJD intervention can be viewed as having been moderately considerate of the power and political dynamics that affect the delivery of primary healthcare throughout
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Sierra Leone. Interestingly, this intervention was the only one that was designed in
Sierra Leone. While the repeated redrafting of the programme document that guided the implementation was more driven by an initial bid to avoid duplicating interventions already underway, the designers were nonetheless aware of the community’s challenges regarding access to free healthcare. NMJD has a history of working on land rights and mining advocacy programmes, and it is therefore well aware of the political economy that drives local leaders and government employees. The evidence suggests that the programme’s biggest weakness was to overlook the power dynamics and politics at the local level: the dynamics that affect the CHMVGs and the District
Health Medical Team.
The intervention made some effort to link the CHMVGs to the DHMT, by inviting
DHMT members to either conduct or attend the training courses that were given to the
CHMVG members. In two cases where the health workers were extremely troublesome, NMJD brought a DHMT member to the community to engage in a
Quality Service Circle meeting. In both cases, the pressure from the health workers’ superiors contributed to improving the behaviour of the healthcare staff. Given that this intervention only targeted ten clinics, it begs the question why the same effort was not made at all ten QSC meetings.82
The complete lack of formal channels of communication between the existing
FMC/CHMVG groups and the DHMT could have been a practical entry point on which NMJD should have lobbied for change. This could have made a lasting difference for other FMCs in Kono: if the DHMT had committed itself to engaging
82 By all accounts it appears as if the NMJD staff did not even attend some of the QSC meetings, they only trained the CHMVGs and let them get on with it. 300 with the FMCs every time it carried out a clinic supervision visit, greater awareness of the healthcare delivery problems may have been achieved.
For reasons that were not clear, NMJD facilitated the attendance of a DHMT representative during the QCS meetings at three out of its ten target clinics. It hereby inadvertently demonstrated the variance between the outcome of QSC meetings that were, and those that were not, attended by somebody who has official oversight duties of the health facilities. The research data suggests that there was a clear difference in health worker behaviour change that seemed related to these meetings being attended by the DHMT representative. This suggests that bringing DHMT staff to meetings where the community can air its grievances regarding access and quality of healthcare delivery can result in positive outcomes. It is unclear if NMJD’s staff even recognised this fact, or if it ever studied the difference in QSC meeting outcome (it was not recorded anywhere nor pointed out by anyone).
Choosing not to challenge the DHMT for failing to carry out its supervisory role was a missed opportunity for NMJD. In addition, by paying the DHMT staff a per diem and providing transport to the communities for the three meetings they attended, NMJD further signalled that it is okay for the local health authorities to shirk their duties and receive a per diem from an NGO for doing the supervisory job for which they already receive a regular salary. If local civil society groups do not challenge the behaviour of district officials, who make a habit of not doing their jobs unless they are paid twice for it, it is hard to see how Sierra Leone can ever arrive at a situation where health workers are held accountable for delivering frontline health services, and where the district health authorities make an effort to achieve this.
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8.5.4 Sustainable staff motivation
Of the four methodologies examined, this intervention facilitated the greatest level of interaction between the CHMVGs and the health workers. The Quality Service Circle meetings provided an opportunity for the community’s opinion about the healthcare they received to be heard, and on giving the health workers the chance to discuss and defend their behaviour during an open dialogue session.
The interviews and FGDs painted a picture of previously conflicted health worker- community relationships, which seem to have improved somewhat in a number of cases. The results were very uneven, but it appears that the health workers who were absent were also the least committed to change, based on the continued charges for free care they allegedly levied. The five health workers I did manage to interview were positive about the improved relationship that had been developed with the community as a result of NMJD’s intervention. Whether it was the improved relationship that came first or the reduced charges for free care that coaxed members of the community into the clinic, is a moot point. Both actions appear to be mutually reinforcing and clearly had a motivating impact on the health workers in question.
While the investment in sub-standard radios undermined the good intention of the radio listening groups, this component could have been a low-cost motivator for the health workers, who are rarely recognised as being lonely and with few peers in terms of levels of literacy or interest.83 The even more mismanaged construction projects also undermined what were well intended efforts to get the community to help the health facility. NMJD’s project designers clearly underestimated what it might take to oversee the construction of a well-built staff quarters or a maternal waiting house. The
83 One health worker told me that she finds it hard to make friends with people in her catchment community and added that she only knew one person in the vicinity who could read or write (HW71). 302 generators purchased under the same community self-help scheme may have created much greater motivators for the healthcare staff. However, their purchase can lead to problems along the way, as highlighted.
8.6 Conclusion
This section concludes the fourth and final case study of this thesis and thereby ends the presentation of the empirical evidence on which this research is based. By examining NMJD’s ‘Mixed Methods’ intervention, the study has been able to include a methodology that was designed in a more iterative manner, in the way scholars of social accountability often call for, but which is rarely possible - due to the often strict confines of donor guidelines. The review of this intervention’s thoroughly mixed bag of sub-components revealed that ‘less can be more’ in programme design. This intervention has provided the opportunity to examine the workings of community- based health monitoring groups and expose the advantages and draw backs of relying primarily on such groups.
Overall, this intervention, which was carried out in quite an inconsistent manner
(especially in the cases when DHMT members were compelled to attend some QSC meetings but not all), offered the opportunity to examine how the different treatment of one target clinic compared to the others, and what impact this appeared to have on the outcome.
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Chapter 9 – Comparative Analysis
9.1 Introduction
In this chapter I will compare the four interventions that have been presented in the preceding chapters. Chapter five examined the Community Monitoring with
Scorecards (CM) intervention, which was focused on community-health worker dialogue. This method was implemented in Tonkolili District by INGO Concern through four local CSO partner agencies. The same agencies also implemented the
Non-Financial Awards (NFA) intervention, examined in chapter six. The NFA intervention was competition-based, aiming to motivate health workers to compete for the honour of being the best clinic in the district.
Chapter seven presented the Participatory Monitoring and Evaluation (PM&E) intervention, which was also an awards competition, implemented by the Ghanaian
NGO SEND, in Kailahun District. This intervention was supported by Christian Aid, which managed the EU funding for it. Christian Aid also supported the final intervention, presented in chapter eight, a Mixed Methods approach which included the
Quality Service Circle (MM/QSC), implemented by NMJD in Kono District:
Chapter: Methodology Implementing agency/agencies Location 5 Community Monitoring World Bank/Concern/OPARD, Tonkolili (CM) COBTRIP, CIDA, Pinkin-to- District Pikin 6 Non-Financial Awards World Bank/Concern/OPARD, Tonkolili (NFA) COBTRIP, CIDA, Pinkin-to- District Pikin 7 Participatory Monitoring Christian Aid (EU funding) Kailahun District and Evaluation (PM&E) SEND Foundation 8 Mixed Methods with Christian Aid (Irish Aid Kono District Quality Service Circle funding) NMJD (MM/QSC)
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In section 9.2 of this chapter the analytical framework will be used to compare how the four interventions incorporated the four key ingredients for social accountability:
Redressing information imbalance Citizen participation Power and political awareness Sustainable staff motivation
This chapter will provide an analysis of the four components and will examine how important they were during the implementation of each of the four social accountability methods in Sierra Leone.
Section 9.3 returns to an analysis of gaps in the social accountability literature. The components of the analytical framework for social accountability were selected after conducting a thorough review of the social accountability literature in advance of the first scoping visit to Sierra Leone in September 2012.84 Evidence from the research suggests that the analytical framework misses two important components: one is the need for ‘adequate implementation capacity’ and the other is the need to ‘collaborate with local/national authorities to stimulate responsiveness’. Section 9.4 will outline what the ideal type of social accountability model suitable for the Sierra Leone context would look like, when lessons learnt from this study are incorporated into the design.
Section 9.5 concludes.
84 That is, three out of the four components were; the staff motivation component was derived from the Human Resources for Health literature. 306
9.2 Comparing the case studies using the analytical framework
In chapter two, I examined the literature on social accountability and deduced that the large majority of social accountability interventions contained the following four components: i) redressing the information imbalance, ii) citizen participation, iii) power and political awareness, and iv) sustainable staff motivation. These four elements were used in this study as an analytical framework. During the empirical research, specific questions were raised around each of the components of the analytical framework to assess whether or not these components were incorporated in the interventions and what results their inclusion achieved. The analytical framework was furthermore employed at the end of each of the four case study chapters to demonstrate the findings of the component-specific analysis of the four social accountability methods.
In the following section, I will use the analytical framework to compare the four different interventions. Using this approach will allow me to deduce with greater clarity which of the framework components were most instrumental in the success (or failure) of the four interventions. The conclusions of this section will further point to significant implications for the design of social accountability mechanisms.
9.2.1 Redressing the information imbalance
The first analytical framework component that was identified as a ‘key ingredient’ in all social accountability methodologies was ‘redressing the information imbalance’. In chapter three, this component was further operationalised. Four indicators were selected to assess this component, and the way in which the four interventions dealt with these indicators is described in the table below. 307
Table 4: Redressing the information imbalance
Interventions: A- Community B- Non-Financial C- Participatory D- Mixed Indicators: Monitoring Awards M&E Methods Nature of the Scorecard info: Clinic staff receives DVD + dialogue CHMVGs tasked information comparing village- clinic ranking. to address lack of to inform gathered and/or level mortality + Deliberate info on free health community on provided other health avoidance of info entitlements. free health (entitlements, indicators w clinic about which Clinic staff get entitlements. service data + FGD info on indicators are used detailed check list CHMVGs are provision staff’s behaviour to judge best clinic of indicators for taught roles + standards, etc.) for non-financial MDG awards responsibilities of award competition CHMVGs Relevance of Scorecard info not Ranking relevant, DVD info in local Entitlement info information relevant to people. but lack of info in language + relevant, but provided (easy FGD collected in indicators leaves accessible to limited reach due to understand, such a way that clinic staff guessing illiterate. Clinic to person-to- does knowing many community re what check list person spreading this matter to representatives improvements to unexpectedly of info people) decide not to make useful for staff disclose problems Target of Service users + Service providers Service users + Service users information service providers service providers provision during joint (service users meetings or service providers) Impact of Very limited Some evidence of Strong impact, Mixed: in some information service provider check list worked locations info led provision behaviour change as job description to great impact, in (catalyst, the clinic staff other places very equalising never had. limited power Community well relations) informed of FHCI
On close examination of the information components that are enmeshed in the four interventions, it is clear that the information can run in two directions:
i. information flows from the implementing NGO/CSO to the community
(info-in)
ii. information is gathered from the community and from the clinics, which is
processed by the NGO/CSO and used as score card or survey data (info-out)
Only two of the interventions had an ‘info-in’ component; the PM&E and the
MM/QSC interventions. Both started their engagement in the community by providing citizens with basic information about their entitlements to free healthcare. The PM&E 308 intervention did this most thoroughly by producing a DVD and showing it in the entire district, ensuring that the women’s group volunteers who were responsible for screening the DVD also held a dialogue session afterwards to check if all messages were understood. The MM/QSC intervention provided its community-based CHMVGs with training and a similar DVD and made the CHMVG members responsible for the dissemination of information. The frequency with which this happened appears to have depended on the commitment of the CHMVG members. The CM and NFA intervention did not provide any information about the free healthcare prior to their implementation.
While the information on people’s entitlements to free healthcare should have been provided through various campaigns that were conducted at the launch of the FHCI, it is clear from the research that many citizens in the target communities had not received sufficient information about their entitlement to free healthcare, and in one or two cases health workers exploited this information gap by denying people free care altogether. The information about the free healthcare policy provided during the
PM&E and MM/QSC interventions was therefore a very useful and well received component.
The means through which important health entitlement messages are delivered to a largely illiterate rural community greatly influences the impact that the information can have. The PM&E intervention started with the creation of a DVD with health-focused sketches acted out by individuals from local communities. This removed several communication barriers; the health messages were able to reach a wide audience of illiterate people who only speak their local language, Mende. Dialogue sessions after the DVD screenings with groups of local women activists helped to further clarify and
309 reinforce the information that was being delivered. As a result, the intervention reached a wide audience.
In the MM/QSC intervention, the community based CHMVGs were provided with a similar DVD85 and the relevant details about free healthcare, which the CHMVG members were expected to deliver to the community. While this had a remarkable success in two communities, where the introduction of free healthcare appeared to have been ignored by the health workers, it had a less significant impact in other places. It is not always easy to ensure that volunteers carry out their task adequately when relying on small groups of community members. It appears that some CHMVGs were very active and reached a lot of people with health messages, while others had a much more limited impact and did not use the DVD at all. The health entitlement messages carried by individuals were also much less consistent than the one delivered by DVD.
The literature on social accountability stresses the point that information (info-in, in this case) provided to the community during an accountability intervention needs to be relevant and actionable. The Björkman, de Walque and Svensson study (2013) demonstrated that when a community is told about the opening times the clinics should adhere to, the hours health workers should be present at the clinic, etc., this information can be used to hold health workers accountable (if they fail to adhere to these standards). Whether a community is empowered to act on information they
85 Because both the PM&E and the MM/QSC interventions were supported by Christian Aid, the two implementing agencies were frequently in touch, with SEND hosting several learning visits and knowledge exchanges with NMJD staff, who were clearly recognised by Christian Aid as being the less experienced CSO. In order to replicate the success SEND had with the DVD, it was decided that Christian Aid would pay for the voice over of the content in the Kono language), so that it could be used by NMJD in Kono District at no additional cost. 310 receive is another matter, but providing the most actionable information is key to starting a transformative process.
Although the two interventions that contained an info-in component provided important free healthcare entitlement information, the interventions did not provide citizens with additional actionable information such as standard clinic opening hours, which could have been tangible entry points for a discussion on, for example, health worker absenteeism.
As the four cases show, social accountability research designs can vary greatly. It is therefore crucial that the right, context specific info-in component is provided, in order to be used as leverage to hold service providers accountable. Implementing agencies need to provide effective methods of delivery in order to ensure that the information component can have an impact (McGee and Gaventa 2010). As the evidence suggests, basic information on free healthcare entitlements was used to demand better access to health services. Additional information on clinic opening hours could have emboldened citizens’ demands, and may have led to greater access to, for example, emergency 24 hour care - which is often mandated by health ministries, but regularly ignored by health workers. Literature on social accountability interventions that specifically focus on ‘nationally determined service standards’ suggests that this is a very useful approach (Bold et al 2010, Pieterse et al 2016).
The second type of information, ‘info-out’, comes with a whole different range of challenges:
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The CM intervention tasked the implementing CSOs with the collection of data on maternal and infant mortality, vaccination coverage, health facility based deliveries, etc., at both community level and at the targeted health centres. The two data sets formed the basis for the scorecards that were used during the community-health worker interface meetings. The scorecards emphasising the differences between the two data sets were supposed to generate discussions about the severity of, for example, mortality rates, which are often found to be higher in village-level data compared to facility-based figures. The problem with this assumption was that the discrepancy between the two data sets was not considered a problem; community representatives assumed that health facilities were not responsible for collecting community-based mortality data. By all accounts, both the community and the health workers dismissed the differences in recorded mortality figures as irrelevant (KI76).
The CM intervention’s score cards had five ‘community versus clinic data’ scores and presented facility ratings on three further indicators: informal charges, nurse absenteeism and staff attitude. The latter indicators could have been useful in terms of generating debate around issues that were found to be at the heart of most clinics’ accountability challenges. However, the way that these scores were collected undermined this part of the scorecard: Focus group discussions with health worker- community representative dialogue participants were held just hours before the actual interface meetings, after the community representatives had arrived at the clinic where the meeting was to take place. The setting and the circumstances under which this data was gathered intimidated participants into not disclosing problems. On the lack of impact the scorecard data had in the community monitoring intervention, the World
Bank consultants wrote, in retrospect:
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In the design, the team assumed the salience of the problem of high mortality and poor health. The assumption was that the scale of the health statistics would make health matters a serious concern and that people would naturally want to act together to make improvements. In hindsight, while health issues certainly affected the majority of households in Sierra Leone, other factors were at play as well. Citizens generally had a low sense of control over health outcomes, adopting a fatalistic outlook toward adverse events. […] In practice, the implementing NGOs had first to educate citizens on basic disease pathways, on how illness is linked to poverty, and how citizens could bring about meaningful change. (Grandvoinnet et al 2014, p. 240)
During the NFA intervention an external agency was employed to collect household data in order to determine the clinic’s ranking, based on utilisation of the clinic for maternal and child health services, health worker absenteeism and charging for free care. As part of the design of the NFA intervention, the implementing agencies were instructed not to provide information to health workers about which indicators were used to determine the ‘best clinic’ winner. The results of the health worker interviews suggest that each of the health workers I spoke to had made some effort to win the award. In this case it appears that the decision to not provide information on the indicators was a missed opportunity: had the intervention design been different and had made it evident that one or two key healthcare indicators would be measured (e.g. full vaccination coverage and facility deliveries), the uncoordinated efforts of the health workers could have had more focus and may have contributed to greater health gains in the target communities.
The MM/QSC intervention used a short, seven-question survey on nurse absenteeism, attitudes and charges, the responses of which were amalgamated into one general list of issues, which were subsequently used to guide the QSC discussions. This undermined the opportunity for clinic-specific problems to be addressed during the
QSC meetings. Testimonies about some of the QSC meetings suggested that clinic-
313 specific problems often emerged quickly during the debates, rendering the survey exercise somewhat redundant.
The PM&E intervention held a series of meetings to choose the indicators for the check list86 which determined the winners in the best performing clinic competition, the MDG awards. Once a year, for three years in a row, the check list was used to determine the best small, medium and large clinics. Although the comment about relevant and actionable information was primarily in reference to the information provided to the community, the research suggests that the lack of such information is also acute among health workers. The PM&E check list was regularly referred to by health workers as a useful guide to ‘the way clinics should be run’. SEND responded to the evident demand for the check lists by printing one-page reminders of the key check list topics and indicators. These lists were found on the walls of many health facilities during the research.
The PM&E intervention showed that the check list containing information on existing standards and policies can also be very useful for service providers, who may not always be aware of these (Franco et al 2002a). SEND staff admitted that the positive reaction to the check list had been unexpected. It is often underestimated how few health workers are aware of basic standards, the research suggested that providing information on how best to improve service quality served as a useful roadmap to the health workers. It was a useful reminder of the fact that many healthcare staff were probably taught in an environment where basic standards were not met and where the emphasis on quality of care may have been lacking.
86 The check list covered everything from proper storage of medicine, clinic opening hours, use of gloves, display of clinic user data, quality of water supply, recording of the minutes of meetings with the facility management team, etc.
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In sum, the info-out component was a key part of each of the four interventions, but the design of this component was a challenge for most. In both the CM and MM/QSC interventions, the nature and the quality of the data that was chosen as ‘dialogue catalyst’ was poor, and this got community-health worker meetings off on a weak start.
Interventions that are based on competitions naturally require data collection in order to determine the best performers to reward. While this was done well in both cases (by two agencies that had a lot of experience in collecting and processing survey data), but, from a sustainability perspective, it has to be borne in mind that designing a competition is not easy, and ensuring the implementing agency has the capacity for data collection and data analysis, can be difficult.
The evidence provided by the analysis of the information components shows that redressing information imbalances is a very important component of a successful social accountability intervention. However, designing the correct information component(s) is far from straight forward: info-in provides a crucial opportunity to level the information imbalance, but it is important to choose the right information to provide, and the right means to provide it. Selecting what information to gather from health facilities or communities can be fraught with design challenges and may need pre-testing before the most effective info-out component is found in any specific context. The unexpectedly positive response to the PM&E intervention’s MDG awards check list suggests that providing health workers with access to information about the standard of service that they were expected to deliver, should not be overlooked.
In chapters 7 and 8, the issue of ‘power-redressing info components’ arose. Evidence from the PM&E and the MM/QSC intervention suggest that information components can help to redress the balance of power between the community and service
315 providers, but that this is not a given. The lack of evidence of well-informed citizens single-handedly demanding the free care that they are entitled to87, seems to suggest that in order for information to empower citizens, the information not only needs to be actionable, it may also be important that the right opportunity is created for citizens to challenge a service provider’s power. The three occasions whereby a DHMT member attended a QSC interface meeting are examples of situations in which this happened. It is unclear to what extent CHMVG members, together with an NMJD staff member, were able to help communities redress the balance of power between them and the health workers, if there was no DHMT staff member in attendance during the QSC meetings.
Overall, the research suggests that strong and well-designed information component(s) are vital for the success of accountability interventions, and ‘redressing information imbalances’ therefore remains a key ingredient of the analytical framework for social accountability.
9.2.2 Citizen participation
The second analytical framework component that was identified as a key ingredient in all the social accountability methodologies was ‘citizen participation’. When this component was further operationalised in chapter 3, it yielded three indicators (table 5, below). Beside the indicators are brief descriptions illustrating how each of the four interventions integrated this particular component into its methodology.
87 These cases may well exist, but none were noted during the eight focus group discussions held in Kailahun. 316
Table 5: Citizen Participation
Interventions: A- Community B- Non- C- Participatory D- Mixed Indicators: Monitoring Financial M&E Methods Awards Whether/not Participation of 5 No community No community Project anchored broad based community participation participation but by working with participation was representatives per component focus on CHMVG who an element of the village formulaic, strengthening of were supposed to initial project little relevance to Facility bridge design FHCI target Management community-clinic groups Committees divide Is intended Intended N/A To some extent, Some CHMVGs participation (if participation was although where not active in any) achieved - achieved w FMCs were community and fully or partially? community inactive, little was the project staff representatives’ done to invigorate did not notice or attendance at these groups were unable to interface meetings reinvigorate the groups The impact, if any, Limited impact N/A Prog documents In some locations of the citizen show that many the community’s participation FMC changed relationship w component membership after clinic staff community’s improved awareness of their dramatically, role though not consistently
The indicator on community participation and citizen engagement paints a complicated picture. The two interventions that contained the least focus on community participation, NFA and PM&E, achieved a greater change in the health workers’ efforts to improve healthcare delivery. The analysis of the CM intervention - which had the largest citizen engagement component in terms of participant numbers - showed that the design of the intervention, with ineffective scorecard indicators, logistical challenges and the weak facilitation during the community-health worker meeting, undermined its success. The CM intervention ignored existing top-down
(district health authorities) and bottom-up accountability mechanisms (FMCs - some of which were active, others largely defunct, but nevertheless an existing community based health monitoring structure). For the health workers and members of the community, the entire intervention appeared to have been no more than three big
317 meetings, which were, not unsurprisingly, perceived by many interviewees as a ‘series of events that happened at community level’ rather than ‘true engagement with the community’. IPA, the agency that was involved in the data gathering for the randomised controlled trial, reflected on these challenges:
Although community participation – through the initiation of community projects or the participation to health management committee meetings for example – is generally associated with higher utilization of government clinics, mobilizing communities that have not demonstrated a pre-existing high degree of cooperation can prove extremely challenging. In addition, local politics and power imbalances between different actors of the healthcare delivery system limits the potential for successful grassroots accountability practices led by end-users. (IPA 2015b, p. 11)
Interestingly, an analysis of the results of the RCT (IPA et al 2015) provided evidence that the community monitoring intervention did have an impact on the health status of the communities in the target areas. However, when the changes that took place are examined, it is clear that the intervention may have had little impact on the behaviour of the healthcare providers, but it did encourage more individuals to seek care at their local clinics. It can be assumed that people switched from using informal healthcare providers such as traditional healers, herbalists and drug peddlers to government clinics, thereby increasing measured indicators such as vaccination coverage and facility births.
The PM&E and MM/QSC interventions worked with community-based health monitoring structures, FMCs (or the enhanced FMCs called CHMVGs in the
MM/QSC’s case). The mixed success in this approach leads to the question that is relevant to all community-based interventions that rely on local monitoring groups: is it feasible to expect that small groups of citizens, many of whom are illiterate subsistence farmers who rely on their local clinic for their medical care, are able to
318 hold healthcare staff accountable for the delivery of decent primary healthcare?
Franco et al believes that this is highly dependent on the circumstances:
Some reforms have tried to reinforce worker links to their communities by making service providers more accountable to community members. This has been attempted through the establishment of district health boards, hospital boards, empowerment of village health committees, etc. These new (or re-invigorated) organizational structures may create an alternative feedback loop, but their effectiveness also depends upon the nature of social relations between health staff and the communities whom they serve.
(Franco et al 2002b, p. 1264)
Durch et al are similarly sceptical, noting that “[…] a wide array of factors influence a community’s health, and many entities in the community share the responsibility of maintaining and improving its health. Responsibility shared among many entities, however, can easily become responsibility ignored or abandoned” (1997, pp. 4-5).
The implementation of the PM&E and MM/QSC interventions seem to have been able to reinvigorate some FMCs through completely different approaches. The PM&E approach included the FMCs in its initial training about free healthcare entitlements. It provided them with information that they may not have had when the groups were first formed. The training’s focus on the roles and responsibilities of FMCs led to an increase in the groups’ knowledge about what was expected of them. This helped a number of groups to overcome their collective action problems - but not all. In the
PM&E targeted area, health workers too were made aware of their duty to interact with the FMCs88 and of taking (and retaining) the minutes of meetings they held with the
FMCs, the presence of which was a ‘checked list item’ for the MDG award survey. In several locations, the PM&E’s intervention led to inactive FMC members being replaced by elected citizens or individuals who showed an interest in taking on FMC
88 By holding monthly meetings and sharing their plans on how to spend the 40% clinic investment component of the PBF funds. 319 responsibilities. The combined pressure from the community, the greater awareness of their roles and a demand from health workers appear to have led to the majority of
FMCs becoming more active in Kailahun (SEND Foundation 2012).
The approach of the MM/QSC intervention was completely different: the active engagement with FMC/CHMVGs was the anchor of the intervention’s activities. Their approach started with summoning the existing FMC, offering the members a stipend for their increased engagement and appointing additional members from outlying villages to the CGMV groups. The tactic appears to have worked well in some locations, but not in others. On meeting the CHMVGs, it was clear that some were led by committed and driven individuals who welcomed the intervention’s support for their enhanced engagement with the health facility. In those cases the group was usually proactive, engaged and successful in improving the relationship between the community and the healthcare staff. However, there were also groups that remained relatively unengaged with the health facility. The research showed that staff of NMJD, the MM/QSC implementing agency, were either unaware of this or unable to motivate these groups to overcome their collective action problems.
Similar collective action challenges were encountered during the CM intervention, where the designers of the programme noted “[…community groups’] low motivation to participate. Intrinsic motivation was low owing to community development fatigue
(too many projects to invest in) as well as the opportunity costs of farming and other livelihood activities” (Grandvoinnet et al 2015, p. 241). When it is uncertain whether personal efforts will ever translate into improved services, it is easy to understand that people are reluctant to offer up their time. And even if there is a chance that services for the whole community will improve, it does not always mean that a select number
320 of individuals are willing to monitor that facility on behalf of the community, potentially jeopardising their own access to healthcare if the monitoring turns confrontational. This type of collective action problem commonly occurs “[…] whenever a desired joint outcome requires the input of several individuals, and yet they fail to provide the required inputs because of their different motivations and interests - often because of the perceived distribution of costs and benefits among them” (Tembo 2013, p. 6).89
NMJD, the MM/QSC implementing agency, tried to overcome the collective action problems by offering a stipend for the work that the CMHVG members carried out.
This seems to have led to some CHMVGs making a greater effort to appear engaged, but without achieving the desired results: during one interview, a health worker-in- charge (HW84) noted he only met CHMVG members once per quarter, when free healthcare medicines were delivered. Paying for community-based monitoring, however little, can also lead to elite capture (Cornwall 2004, Crook and Sverrisson
2001), with prominent community members taking on the role in order to receive the stipend, but without being interested in carrying out the accountability work. In addition, paying FMCs can undermine the sustainability of the system and make it less likely that the groups will remain active once the programme phases out and the stipends are withdrawn.
89 One way in which the implementing agencies of the Ethiopian Social Accountability Program have overcome collective action problems in the health sector, was, paradoxically, by engaging those who were most vulnerable. Throughout the ESAP2 programme, ‘empowered’ groups of people with disabilities and those living with HIV often proved to be the most engaged health monitors. They stood to benefit most from improved health services and few had jobs or farming to do, which meant that their opportunity cost for engaging in monitoring activities was low while their potential gains were high. My work experience with the Ethiopian Social Accountability Program has shown that this often occurred when people living with HIV or disabilities were ‘elevated’ in status to become daily/weekly monitors of local health services: many were very effective monitors, therefore benefitting the wider community and receiving great social capital from their role in the process. 321
NMJD, the agency that implemented the MM/QSC intervention, had limited transport available and this appears to have resulted in the project teams’ frequent visits the
CHMVGs attached to clinics that were closest to Koidu town (here the implementing agency NMJD had its base) compared to the attention given to the more remote clinics.90 Incidentally, the CHMVGs close to Koidu were also the more active ones.
While it was difficult to verify in this case91, it would not be surprising if a strong correlation existed between the amount and quality of support that a CHMVG received and its effectiveness.
Working with FMCs, or village health committees, as they are known in many other parts of the world, remain a common approach to citizen engagement in healthcare delivery in developing countries (Molyneux et al 2012, Uzochukwu et al 2011). Those who design social accountability interventions with a strong village health committee component could learn from past experiences written up by other practitioners, as small details can make a great difference in the design. Durch et al, for example, note the difference between an elected and an appointed group of monitors, who chose to take on the role of monitoring:
The committee proposes that accountability for those actions be established within a collaborative process, not assigned. Performance monitoring is the tool that communities can then use to hold community entities accountable for actions for which they have accepted responsibility.
(Durch et al 1997, p. 5)
90 When it became clear that the NMJD programme would be run by the Kono field staff only (the assigned programme officer largely withdrew his engagement), the organisation hired a second Kono based staff member. The Christian Aid governance advisor complained that the new staff member was neither sufficiently trained or experienced, nor could she ride a motorbike, so the existing staff member still had to accompany his new colleague everywhere, which meant that the intended workload reduction did not materialise. 91 Of the two NMJD programme staff who worked on the programme, one roundly admitted that the nearby clinics received twice as many visits as the outlying ones, while the other staff member insisted they visited all clinics the same number of times: based on personal interviews with NMJD field staff (KI79 and KI78). 322
Interestingly enough, despite the fact that the CM intervention contained no explicitly
FMC-focused component, evaluations showed that both the CM and the PM&E methods were linked to greater FMC activity at the end of the intervention, showing that greater awareness of accountability issues spurred communities on to reconstitute or reinvigorate unresponsive FMCs. This shows perhaps that when the motivation to demand accountability originates in the local community it works better. The challenge thus becomes to identify how implementing agencies can motivate these committees in a sustainable way. It suggests that ‘citizen participation’ is not only about being able to create space for the genuine participation of all types of citizens, it also includes a challenge for social accountability implementing agencies ‘how to sustainably enable citizens to overcome collective action problems’.
Overall, it is hard to quantify the general change in accountability and the contribution provided by additional pressure that emanated from an FMC. It was unclear if the stipend (MM/QSC), the roles and responsibilities training (PM&E) or just simply having a health focused intervention in the community (CM) led to greater efficacy of the local oversight bodies. The literature suggests that the sustainability of the FMCs is something that can only grow organically over time, with the wider community appreciating and encouraging FMCs to continue to play an active role transforming the accountability relationship between service providers and service users.
What does seem to have contributed to a greater frequency of FMC-health worker meetings was the inclusion of a ‘pull factor’; the PM&E check list awarded points for the presence of the minutes of monthly FMC-health worker meetings. This obviously did not guarantee the quality of such meetings, but at least if they were held, the chance that a greater engagement occurred was more likely. The provision of
323 information about healthcare entitlements and the FMCs’ roles and responsibilities may not always be able to encourage greater citizen participation, but at least it removed some of the barriers and created communities that were ‘enabled’ for greater engagement.
The lessons learnt from the analysis of the citizen participation component were: sustainable citizen participation cannot be ‘implemented’, it needs to grow organically.
Creating the right conditions for citizen engagement can help. The evidence from the case studies showed that i) a formulaic composition of monitoring group members can undermine the involvement of individuals who are willing and able to take on a monitoring role; ii) providing FMCs with training on roles, responsibilities and information about healthcare entitlements can create an enabling environment in which
FMC can flourish; iii) regular face to face contact with CSO staff who are supportive of monitoring activities may also prompt FMCs to be more active; and iv) finally, by providing an incentive for health workers to document monthly meetings with FMCs, it is possible to increase FMC-health worker engagement, but this cannot guarantee the quality of the issues discussed.
9.2.3 Power and political awareness
Awareness of power and politics is the third key ingredient of the analytical framework. Operationalised in chapter 3, this component was subdivided into three indicators, found in table 6, below. Beside it a brief description is given to illustrate how each of the four interventions integrated this particular component into their methodologies.
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Table 6: Power and political awareness
Interventions: A- Community B- Non- C- Participatory D- Mixed Methods Indicators: Monitoring Financial M&E Awards Awareness of Either unaware or N/A Yes, the Some, while NMJD common accepting this as intervention was staff was heavily accountability normal: interface designed to address involved in deficits among meeting facilitators accountability improving NGO staff, and were willing to deficits at clinic but behaviour of some how they affected accept health workers also district health clinic staff, health service users excuses for authority level unaccountable unaccountable behaviour at other behaviour without clinics was questioning it overlooked Strategies to No, the design of the N/A To some extent by In several cases address power programme included improving citizens’ DHMT staff was imbalances at no engagement with FHCI awareness, brought to interface community level health authorities FMC’s greater meeting, greatly who could have understanding of increasing the balanced power role + better DHMT leverage the engagement in CHMVG had over monitoring clinics clinic staff District-level None N/A Yes, PM&E team Better linkages linkages that were worked closely with between some used as leverage to DHMT, improved CHMVGs and address their capacity and DHMT but not at all accountability contributed to clinics failures greater top down monitoring
In this section, I will focus on obvious actions92 implemented as prescribed in the project guidelines of all four interventions that speak to understandings of the accountability problems in the health sector. Furthermore I will examine the power imbalance between health workers and the community, and on the role the accountability interventions played in getting the district health authorities involved in improving health worker responsiveness.
Two interventions, CM and MM/QSC, used the community-health worker dialogue as their main vehicle for the improvement of health worker accountability. Neither intervention was very successful. In both interventions, the facilitation of the dialogue
92 It is possible that some of the programme designers’ awareness of such issues may not be recognisable when the programme is being implemented, maybe due to time and financial constraints or due to a lack of implementation capacity. 325 meetings seems to have been poor. This led in a number of cases of health workers dominating the dialogue sessions and rebuking accusations of misconduct. Copies of
CM’s community compacts accessed at the Concern office93 show repeatedly that health workers and facilitators interpreted the community representatives’ complaints about being charged for free care as ‘women not understanding the free healthcare policy’, not health workers’ transgressions. Community members who attended some of the meetings recalled being intimidated by the health workers and decided not to raise any serious problems. The CM’s scorecard information and the aggregated questionnaire outcome used in MM/QSC were both ill-conceived data sets that did not meet the most basic requirement of information that can counter the existing information imbalance between the community and health workers; it was not practical or actionable.
The CM implementation guidelines did not require that the implementing agencies ensure a health authority representative attended the dialogue sessions (Grandvoinnet et al 2014, p 243). The organisation that implemented the MM/QSC did arrange for a
DHMT representative to attend several of the QSC dialogue meetings, but not all.
During the three cases where a health authority official was present at a QSC dialogue meeting, the impact on the health workers’ behaviour was significant. The attendance of a district official occurred in two places where a particularly troublesome health worker was employed, while in the third case the health official’s attendance seemed more random. Especially in the two troublesome cases, the meetings had a great impact on the community’s access to care. In one case, the health worker (HW104) admitted, the meeting led her to relocate to the village where the clinic was based, instead of commuting from a nearby town for a few days every week. She also realised
93 These were found in the programme documentation folders at the Concern office in Magburaka. 326 that her aggressive tone was inappropriate and “stopped shouting at patients”. In the second case, where the alcoholic health worker and his deputy had completely ignored the introduction of the free healthcare, the meeting led to the deputy health worker taking control of the clinic and subsequently charging reduced significantly. There was no clear indication as to why the third location was chosen as the place where NMJD decided to send a DHMT member to. While in all three cases where a health authority representative had attended a QSC some informal charging for free care continued, but it was either negotiated or relatively minor. It is unclear why NMJD, the implementing agency of the MM/QSC method did not facilitate the attendance of DHMT staff at all of the other QSC meetings: the intervention only targeted ten clinics, so it held only ten QSC meetings in total – not having brought them was clearly a missed opportunity.
In summary; evidence suggests that where interface meetings took place, facilitation of the meetings was weak and inadequate in terms of addressing the power imbalance between the health workers and the Figure 13: Power imbalance between health worker and citizens – levelled by DHMT or NGO presence community. The success of the few dialogue sessions at which a local health authority official was present, suggests that in the
Sierra Leone context, the power imbalance between frontline healthcare providers and women who are entitled to free healthcare was such that the peer pressure members of the local community alone can bring to bear simply is not sufficient to compel health workers to change their behaviour. Regardless of the quality of facilitation, the presence of a DHMT staff member was clearly the decisive component that drove the 327 health worker behaviour change in the CM and MM/QSC interventions. I illustrated this point with figure 11 during a research findings feedback session in Freetown in
May 2014.
Those who designed either the CM or the QSC interventions underestimated the fact that the great power differential between the community and the health workers would be a major barrier to frank and open dialogue sessions. They encountered health workers who were surprisingly power aware, and used this knowledge to great effect: a case study written by a World Bank consultant remarked on how health workers selectively mistreated patients:
Some clinic staff adopt a “divide and serve” approach, providing attentive care to the more influential members of the community (who may have some authority to question non-performance or to offer resources in return for services) and providing too little care to less powerful members of the catchment. (Grandvoinnet et al 2015, p. 237)
Only the PM&E intervention included a significant component that focused on working with the local health authority. The PM&E intervention included a significant training component which was designed to strengthen the DHMT’s M&E capacity.
The PM&E intervention did not include community-health worker dialogues: it primarily focused on improving the top-down monitoring - with a minor ‘FMC strengthening component’ to somewhat increase the bottom-up demand for greater accountability. The PM&E’s survey was presented to the DHMT as a model of how all clinics should be monitored, and the PM&E staff engaged the DHMT in its decision making regarding the selection of the MDG award winning clinics, which led to more frequent monitoring visits by DHMT to all the clinics in the target districts.
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It is striking that the greatest health worker behaviour change occurred in clinics that were targeted by the PM&E intervention and in the three instances whereby a DHMT staff member attended a MM/QSC interface meeting. This shows the importance of engaging both the community but also the local authorities in a bid to improve health worker behaviour, confirming the emerging consensus among social accountability scholars such as Tembo and Fox. The latter wrote:
More promising results emerge from studies of multi-pronged strategies that encourage enabling environments for collective action and bolster state capacity to actually respond to citizen voice. This reinterpretation of the empirical evidence leads to a proposed new series of grounded propositions that focus on state-society synergy and sandwich strategies through which ‘voice’ and ‘teeth’ can become mutually empowering.
(Fox 2014, p. 5)
The PM&E intervention combined a number of different components that reinforced each other and led to the significant health worker behaviour change: i) the intervention had strong links with the DHMT, whose representatives’ more frequent clinic visits improved top-down monitoring of all the clinics; ii) the top-down monitoring by a well-connected and capable CSO using the check list, further reinforced the health workers’ impression that they were being monitored by those who had links to the DHMT; iii) the intervention made a significant prize available for the clinics that won the MDG award; and iv) the intervention avoided relying too heavily on community-based, bottom-up pressure only.
A fifth and final ‘winning’ element within the PM&E intervention was perhaps the fact that by not engaging significantly at community level, it avoided becoming involved in local level politics, in which town chiefs and paramount chiefs and local counsellors all have their own incentives for meddling with the various aspects of healthcare delivery (Gerbie 2002, Keen 2003), as was evident in chapter six. By not engaging at
329 this level, but instead by influencing those responsible for monitoring and oversight, the programme showed itself to be the most politically aware of all.
In a time when several influential social accountability scholars had already started to talk about working on the improvement of service provider accountability through a combined bottom up and top down approach, it is surprising that two out of the four social accountability programme designs ignored the ‘top down’ element, neglecting the fact that pushing local authorities to be more responsive to the greater ‘bottom up’ demand for accountability at grassroots’ level can lead to better outcomes (service providers who feel the pressure from both directions are more likely to respond). As
Joshi and Houtzager stated in 2012:
Our own research and that of others suggests that social accountability in the form of demand side pressures by itself is unlikely to be successful. Successful cases rely heavily on reforms or support from the supply side in the form of reformist bureaucrats, alliances across the public–private divide and changes in the broader incentives within which the public sector operates (CFS 2010; Booth 2011).
(Joshi and Houtzager 2012, p. 153)
Overall, the evidence suggests that power and political awareness is crucial for a successful social accountability intervention. Improving accountability is inherently about power, and it is therefore not a surprise that the intervention that showed greater power and political awareness was able to achieve the greatest behaviour change in frontline healthcare staff. Especially in challenging operating environments in which the leadership “lack either the political will or capacity to deliver public safety and basic services to all their citizens” (OECD 2008), a thorough understanding of what drives local authorities and service providers to improve their efforts to deliver basic services is important.
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9.2.4 Sustainable staff motivation
The fourth ‘key ingredient’ for the analytical framework for social accountability is
‘staff motivation’. Operationalised in chapter 3, a total of four indicators were selected.
To provide a quick overview, these indicators are described in table 7.
Table 7: Sustainable staff motivation
Interventions: A- Community B- Non-Financial C- Participatory D- Mixed Methods Monitoring Awards M&E Indicators: Presence of / None Yes, participating The best small, In 2nd year of approaches to clinics were medium and large implementation a motivational promised a non- rural clinic in ‘community elements within financial award Kailahun won a initiative’ was added intervention for the best and motorbike, fuel to prog, during most improved vouchers and cash which villagers facility in annual MDG constructed staff awards. Radio and house, maternal district health waiting rooms or authority attention bought generator for were also clinic staff (w important. NMJD’s financial assistance). Levels of Few, other than Some, the Krio, Significant Reasonable awareness of the in a write up of the NFA awareness of the awareness shown role of staff programme programme was need to motivate primarily through motivation with which typifies called ‘respect clinic staff and introduction of the regards to staff method as a non- pass money’ also to provide community initiative behaviour confrontational meaning that it them with a approach was more significant award important for which would clinic staff to earn create an incentive the respect of for behaviour peers rather than change monetary prize In interventions N/A Yes, non-financial Intrinsic N/A with an award: award, it motivation not was award specifically undermined by suitable focused on intervention, most regarding intrinsic clinic staff excited intrinsic motivation to be recognised motivation? for achievements, even as runners- up. In interventions N/A Yes, every health Yes, every health N/A with an award: worker worker made some did it offer an interviewed was attempt to win incentive to able to point to award, many made improve several significant behaviour? improvements changes, made as result of constructing NFA intervention toilets, waiting areas, etc. 331
This fourth component does not have the same prominence in the social accountability literature as the other three. As noted in the literature review, this is surprising, since staff motivation is clearly linked to the ‘social’ side of social accountability. The evidence from the classic social accountability method Community Monitoring provides some hints as to why this may be. Social accountability interventions are programmes that are largely focused on the citizen engagement side of service improvements, which steers the focus away from the interactions these interventions can (and should) have with service providers. Continued scans of the sector specific literature show that within the health or education sector literature (focused on developing countries) there appears to be little engagement with social accountability interventions. Nevertheless, this research shows that sustainable staff motivation is an important component.
Tackling unaccountable behaviour in the health sector in Sierra Leone is a challenging issue and there are good arguments for and against stronger sanctions for transgressions. On the one hand, there are ground rules about which behaviour is and is not acceptable for health workers, and transgressions include: selling medicines that should be free and charging for free care. Unaccountable health worker behaviour discourages people from seeking medical care at government facilities and promotes the use of unsafe alternatives such as herbalists or drug peddlers (McPake et al 1999,
Vian 2007). Charging for healthcare delays care seeking, and delays in treatment contribute to Sierra Leone’s staggeringly high infant, child and maternal mortality rates, which are among the worst in the world (UNDP 2014).
Regardless, one cannot consider the former without also paying attention to the many challenges health workers face when they are doing their job in a rural area of Sierra
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Leone. Young health workers often graduate having gone into debt in order to qualify, and are sent to work in remote locations. Recently graduated health workers were assigned to a clinic and expected to work without pay for up to eight months after starting a job, with no back pay for the months worked. Starting salaries are low, health workers have limited time off94. Some were forced to live in a single room in a clinic or in a small room behind it. The majority of rural clinics do not have access to electricity, limited phone coverage and some do not even have access to safe and clean water (HW56, HW66, HW93).
Before engaging in the sanctions versus motivation debate, it has to be clear that
NGOs cannot punish healthcare staff: that is the responsibility of the district level supervisors within the Ministry of Health and Sanitation who are charged with managing and overseeing all frontline healthcare staff. When management and oversight fail to ensure that healthcare staff carry out their duties in a satisfactory standard, NGOs can sometimes help to support citizens to hold frontline staff accountable, or they can try to motive staff to improve their behaviour.
The NFA and PM&E interventions were focussed on the latter: they offered health workers the chance to win an award for running the best performing clinic and thus aimed to motivate health workers to improve health service delivery. In a setting where health workers were rarely praised and never invited to participate in the design of a monitoring framework or in a competition, it was clear that the novelty of the interventions was one of the reasons why health workers made an effort to win. The two approaches were quite different: the PM&E’s ‘MDG awards competition’ offered clinic managers a chance to win a motorbike for the clinic, fuel vouchers and a cash
94 If a health worker is the only trained staff member assigned to a clinic, there is technically no time off, s/he is always on call. 333 prize. The winners of the NFA competition received a wall clock and a certificate signed by the president (but were not told that this is what they would receive). The clinics competing for the MDG award were provided with an extensive check-list on which their clinics were judged, while health workers in the area where the NFA competition was held were only told about their clinic’s initial ranking; the health workers had not been provided with any information about which indicators the ranking was based on and were given no direction in terms of how they could optimise their chances of winning the award.
Interestingly, the interviews with the health workers in both locations showed that all staff in participating clinics had made some effort to improve their clinic and win the award (HW01). In the PM&E area, health workers had used the check-list to guide them, and in the case of the larger clinics95, clinic managers reported traveling to the clinic that won the previous year just to see what actions they could replicate in order to win the award. Charging for free care was one of the many indicators on the MDG awards check list. The focus group discussions with clinic users I conducted in the
PM&E area show a conspicuous absence of complaints about charging. The health workers competing for the NFA made a range of efforts to win the prize, but the lack of guidance meant that health workers took a number of different approaches.
Improving the frequency of outreach visits was the most common response, followed by setting a clearer schedule for ‘clinic days’.96 While this may have had a positive impact on the community’s access to vaccinations and ante-natal care, it was not enough to improve the health status of the community in the short run: the evaluation
95 Sierra Leone has three types of rural clinics: Maternal and Child Health Posts; Community Health Posts and Community Health Centres, which have catchment communities of less than 5,000; between 5,000-20,000, or 20,000 and higher respectively. The MDG competition offered a prize for one winning clinic in each of the three categories for three consecutive years. 96 Inviting all pregnant women to come on a pre-agreed day every week, inviting mothers with children under five to come for growth monitoring or vaccinations on another day of the week. 334 by the World Bank and the data gathering agency shows that the community-based health indicators on which the competition winners were judged barely improved in areas where the NFA intervention was held (IPA et al 2015).
The health workers in the PM&E area found the MDG awards intervention a positive and motivating experience; staff reported “feeling empowered after winning the MDG award”, saying “it gives me zeal to work hard and win this award” and “[the awards] are encouraging health workers to come up to that standard, that is a good thing."
(HW01, HW07, HW17). In contrast, the health workers in the NFA area did not have any strong feelings about the intervention; almost a year after the health workers received the first visit, nobody was clear if a winner had been selected and which clinic had won. This certainly undermined the motivational component of the competition.
The CM intervention had hoped to achieve greater health worker motivation by facilitating community-health worker dialogue sessions. These were supposed to lead to greater cohesion and joint problem solving, as the methodology did in other countries where it was implemented (Björkman and Svensson 2007, Ho et al 2015). It appears that the aforementioned problems of weak facilitation and power differentials were too large to overcome, and largely prevented successful meetings of minds between health workers and health user communities.
In addition to competitions or dialogue sessions, other motivational tactics were noted: the implementers of the Mixed Methods approach included a ‘community contribution component’ to the intervention, a year after the intervention had started, to respond to the demand from the community (and some of the health workers) who wanted to address some of the living conditions of the health workers by building staff quarters
335 or buying a generator.97 The three healthcare staff who had recently received a generator (just weeks before I interviewed them), were understandably very excited about this. Whether the generators were actually perceived as a gift from the community or from NMJD was unclear. The health workers who were waiting for the community to finish the construction of the staff quarters were less excited by the prospect and only one expressed their gratitude for the community’s initiative, possibly because it had taken a long time to reach even the halfway point in the construction.
The impact of the PM&E intervention provides evidence that it is possible to motivate frontline healthcare staff to improve healthcare outcomes, even with a predominantly
‘top down monitoring’ approach. I believe that the significance of the award package on offer contributed to the health workers’ decision to respond positively to the competition; for many, the prospect of winning provided the right incentive to change their behaviour. While the behaviour change was less pronounced, the NFA competition also motivated health workers to make a greater effort than usual to win the award.
In both competition interventions, the question of sustainability was left unaddressed:
The NFA intervention was clearly designed to last only for the duration of the implementation: when you hold a competition for an undisclosed ‘non-financial award’ you know that people will be less enthusiastic when they find out what the award actually is. It is not impossible to hold competitions with only praise and recognition as rewards, but in order to do so, the organisors need to invest in follow-up after the winner(s) are announced, provide media coverage and other ways of ensuring that public recognition becomes a motivating factor.
97 In two cases the community appeared to be constructing a multi-purpose space which could serve as staff accommodation and maternity waiting house. 336
The PM&E was designed as an example of how top-down monitoring could be implemented by the DHMT, however, the programme did not attempt to ‘hand over’ its monitoring system to the DHMT, it merely tried to improve the DHMT’s monitoring by engaging key staff in the PM&E process. There were a number of reasons why the PM&E method could not easily be sustained by the DHMT. A staff member of the DHMT immediately identified the significant value of the prize money as a reason why the DHMT could never continue with a similar monitoring and prize giving system (KI26). I believe that the DHMT’s lack of data gathering and data analysis capacity would have been greater factors. In addition, the DHMT’s reluctance to visit clinics unless its staff members could claim a per diem (and have sufficient fuel in their vehicles) would have been another stumbling block.
The lack of sustainability appears to be the biggest downside of the competition interventions; however, there were suggestions that some of the improved work ethic could have lasted beyond the end of the intervention. More research would have been needed to ascertain the extent to which the improvements that were made in the context of an award for improved interventions were generally maintained.98
One additional point on motivation: it seemed as if the approach taken by the PM&E intervention appealed to health workers as ‘professionals’ in a way that none of the other interventions did. The PM&E method involved several health workers in the design of the monitoring survey and it used Sierra Leone’s healthcare policies as its starting point, which made the survey relevant and objective. Grandvoinnet et al note:
“Appealing to an official’s professional reputation or personal integrity can sometimes
98 The last field research trip took place just weeks before the first Ebola cases were confirmed in Kono and Kailahun in May 2014. It is extremely likely that the clinics where the interventions under study took place were affected by the epidemic, sadly, it will therefore be impossible to carry out such follow- up research on these specific interventions. 337 effect change. At times, social norms may override political constraints. Service providers and government officials can be responsive if they are driven by professional norms or their standing in a community” (Grandvoinnet et al 2015, p. 172). The desire to uphold one’s professional reputation can be considered a form of intrinsic motivation.
While the design of every intervention should take the issue of undermining intrinsic motivation seriously, not every accountability intervention’s objective of motivating staff will always work as intended. In places where fractious relationships exist between service users and service providers (Hossain 2009, Ho et al 2015), an improved relationship between the two parties may be all that can be hoped for. And in places where a competition works, it cannot always be said that the winning health workers spontaneously become intrinsically motivated to do a better job: in many cases their desire to win is a selfish impulse, not an altruistic one. However, it was observed that many health workers who participated in the PM&E intervention experienced something of a ‘virtuous circle’ effect, whereby the clinic improvements elicited positive community responses which reinforced health workers’ drive to improve services further.
Through the analysis of the ‘staff motivation’ component of the four social accountability interventions, three different types of motivators can be identified: i) health workers’ internal and intrinsic motivation, which can be heightened by peer pressure/sympathy with patients, or through an appeal to professional values; ii) motivation to improve work practices in order to win a prize; and iii) motivation to improve work practices because of external pressure in the form of greater scrutiny from local health authorities or from an external monitoring agency.
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All in all, staff motivation, the fourth ‘key ingredient’ of the analytical framework can also be an important part of social accountability interventions, though its importance is often overlooked. However, as this research has shown, in some cases where service providers do not respond well to peer or community pressure, they may respond to a competition. For the four interventions under study for this research, that seems to have been the case.
9.2.5 Conclusion
The research provided evidence to suggest that the four elements of the analytical framework were important factors in the success, or partial success, of the four social accountability interventions. Examining the results of all four analytical framework components together, it is clear that the Participatory Monitoring and Evaluation method performed strongest in terms of incorporating the four key ingredients successfully and achieving the desired results in terms of improving health worker accountability.
The following section questions the completeness of the analytical framework that was composed for this research. The components were selected from the academic literature on social accountability that was available at the start of this research project.
The analysis of the four ‘key ingredients’ for successful social accountability interventions has taught me that all four of the components are indeed important, but that others should be considered.
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9.3 Gaps in the literature: additional factors can improve accountability in the health sector
9.3.1 CSO capacity as a ‘success factor’
Throughout the examination of the four social accountability interventions the evidence has suggested that SEND’s Participatory Monitoring and Evaluation intervention was significantly more successful in achieving its stated goal of
‘improving healthcare delivery through the improvement of accountability’ than the other three interventions.
Until now the analysis has mainly focused on the methodological differences that contributed to the success of the PM&E method. This section will focus on the additional reasons why certain interventions struggled to achieve the results they aimed for and others were relatively successful. First of all: a lack of sufficient implementation capacity.
Evidence suggests that the PM&E method’s success arose not only from the operation of an appropriate methodology but on the availability of staff with strong, pre-existing capacity. SEND’s staff had worked with the methodology before, and many of the
SEND team members had worked with the organisation for an extended period of time. As noted in chapter seven, the organisation had brought several Ghanaian staff members to Sierra Leone, because it realised that it was difficult to find well educated
Sierra Leoneans who had the required work experience and would be willing to live and work in Kailahun (which is situated a ten-hour drive away from the capital
Freetown). This approach was in marked contrast to the agencies that implemented the
CM intervention, which, as noted in chapter five, hired staff with limited qualifications
340 and little relevant work experience. NMJD, the agency that implemented the MM/QSC methodology described in chapter eight, worked with a Freetown-based ‘technical programme manager’, who was largely absent when it came to field visits, while it hired two Kono-based staff with very limited technical expertise or work experience that was suited to the Mixed Methods intervention.
The need for strong implementation capacity is often treated as a given. Hoffmann makes a particular mention of the need for good facilitation during social accountability interventions in his 2014 review of NGO experiences of using social accountability to improve health outcomes:
Facilitators with negotiation skills are critical for these activities to succeed. Facilitators need to have respect for citizens, be trusted by the community, have knowledge of the local language and culture, as well as CSO and NGO context, must not foster a vertical relationship, and not be in a position of power or authority within the community. The facilitator must know how to encourage involvement and participation. Toolkits and field guides exist for partners in the field to adapt when implementing the activities; facilitators should be very familiar with the activities involved in each step. (Hoffman 2014, p. 18)
CSO capacity is obviously much more than just facilitation skills, senior management has to be visionary but also practical, ensuring there are sound financial systems and human resource support in place, and that junior staff is trained and well supervised.
Due to a lack of emphasis on implementation capacity, staff working for NMJD and the four CSOs contracted by Concern to implement the CM and NFA interventions99, had less experience in implementing citizen engagement interventions than SEND.
This was evident in weak facilitation and badly managed support to community groups. In addition, there was evidence that pointed to implementing agencies not having organised the required number of meetings they were expected to organise.
99 The CSOs: CIDA, COBTRIP, OPARD and Pikin-to-Pikin. 341
Two reports by the international civil society action group CIVICUS, together with the
Sierra Leone CSO Campaign for Good Governance, make it clear that capacity and impropriety challenges within the CSO sector are common in Sierra Leone. One paper notes: “Internal governance weaknesses persist in CSOs because some leaders of non- membership organisations, in particular, gain from these” (2014, p. 7). The same report further notes that while service delivery CSOs have made some improvements in terms of complying with regulatory demands, many agencies have few permanent staff, rarely engage in staff training or strategic planning and have a weak resource base.
This too was confirmed during the field research; the director of OPARD, noted that the agency had few full-time staff and that even its full-time employees occasionally
“return to farming” when there are no externally funded interventions to carry out
(KI65).
Donor agencies and INGOs engage Sierra Leone CSOs on the assumption that CSOs’ management structures are sound and that the required capacity is available in-house, needing little investment other than programme specific capacity-building (Campaign for Good Governance/Civicus 2014, pp. 7-9). Evidence suggests that these expectations are simply not realistic. The Civicus report noted that “international organisations [which] still give funds to CSOs that openly have dubious legitimacy and elastic mandates can encourage CSOs’ institutional weaknesses”, while the INGO practice of providing minimal support to implementing CSOs makes it impossible for agencies or individuals to improve in-house CSO capacity.100 It appears to be an overlooked fact that Sierra Leone emerged from a civil war in 2002 with 67% of its
100 Having said this, the report also notes that “a practice is now emerging of international non- governmental organisations (INGOs) entering into multi-year partnerships with local CSOs, particularly civic organisations, to implement projects in which the financial and administrative practices of local CSOs that receive funds are enhanced. These multi-year partnerships are also helping civic organisations to adhere to coherent mandates and demarcate their areas of specialisation” (Campaign for Good Governance/Civicus 2014, p. 7). 342 school-aged population out of school; even in 2006 the country only had a 37.1% adult literacy rate (Wang 2007). Greater investment in improving the capacity of Sierra
Leonean CSOs and incentivising better CSO management will be needed, in order to support the emergence of a strong ‘development-focused’ civil society.
Given that the components of the analytical framework were selected from the literature on social accountability, it is surprising that the issue of implementation capacity has not been referenced more frequently. One of the reasons why this gap may exist is that such assertions may sound like criticism of the entire NGO sector. In the past decade, a new body of literature has grown up around the issue of NGO and
CSO accountability (Agyemang et al 2009, Jordan and van Tuijl 2006, Walsh 2014).
However, linkages between these two bodies of literature are close to non-existent; the literature on social accountability does not recognise CSO capacity and internal
NGO/CSO accountability as a barrier to holding public service providers accountable.
The literature on social accountability needs to acknowledge that the realities of corrupt NGOs, briefcase CSOs and the deliberate skimping on implementation contracts should not just be brushed aside as the “much publicised cases of financial incompetence and in some cases fraudulence in a few NGOs in different parts of the world” (Naidoo 2004, p. 18). If the literature on social accountability is expected to assist practitioners to implement these methodologies in a strategic and context-aware manner, social accountability scholars have to face up to the fact that well-recognised requirements for social accountability interventions should include the necessity to work with professional implementing partners that are well run entities which can provide sufficient implementation capacity. Especially for practitioners who aim to implement social accountability interventions in fragile or post-conflict state contexts,
343 where CSO capacity is often weaker and more prone to elite capture (de Weijer and
Kilnes 2012, Verkoren and van Leeuwen 2014) this issue deserves greater recognition.
So too does a completely different aspect of the role of civil society in accountability interventions. While the need for sufficient implementation capacity is the number one priority, a debate does also need to take place around the question regarding the challenges of civil society agencies as intermediators between governments and citizens (Jordan and van Tuijl 2006, Peruzzotti 2006). In his address to the Global
Partnership of Social Accountability forum in Washington DC in May 2016, John
Gaventa proposed that “Social accountability is the bridge for building relationships between citizens and the state” (2016). This does raise expectations in terms of the capacity of those who are tasked with building that bridge, not only do they need to be good facilitators and negotiators, they need to be able to build trust on both sides of the water, while at the same time ensuring that the temporary bridge does not discourage people from learning how to swim, metaphorically speaking. A successful social accountability intervention enables the amplification of citizen voice so that the relevant authorities can hear it and respond to it, without taking away government’s sense of responsibility for listening out to citizens’ voices or carrying out oversight to ensure that government contracted public service providers accomplish their daily duties diligently and equitably. Getting the balance right is not easy.
9.3.2 Promoting government responsiveness
A second component that deserves greater reflection is the ‘engagement with local government authorities’. This element was strongly present in the PM&E intervention and to a lesser extent in the MM/QSC methodology. The PM&E intervention invested 344 a lot in the promotion of responsiveness of the District Health Authorities in Kailahun.
SEND’s training courses made DHMT staff aware of the relevant policies they were supposed to implement and reiterated their oversight responsibilities (KI26, KI30).
Practical assistance in terms of transport to all of the clinics whenever monitoring visits took place brought them in closer contact with health workers throughout
Kailahun District. The programme ensured that DHMT staff were always centre stage during awards ceremonies and the annual Kailahun Health Summit, which helped them appreciate their role as ‘health leaders’ (KI30). NMJD, the agency that implemented the MM/QSC intervention, had fewer planned engagements with DHMT staff but maintained a good relationship with key personnel. NMJD provided transport and per diems for DHMT representatives to attend several QSC meetings and, in one case, it brought DHMT staff to a village to mediate in a community-health worker dispute.
In both interventions it was clear that the involvement of DHMT staff, who are legally mandated to provide oversight and supportive supervision, leveraged the communities’ and the Facility Management Committee’s power to hold health workers accountable.
In several cases this effected real change. It confirms that promoting accountability is not only a case of stimulating the bottom-up demand for better services: greater transparency and responsiveness from both service providers and local authorities are equally important. In places such as Sierra Leone, where the incentives to respond to such bottom pressure are few, it helps to ‘push from both directions’; promoting authorities’ responsiveness by making their inclusion an important part of a social accountability intervention.
Jonathan Fox, who coined the phrase Strategic Social Accountability, concluded in his
2014 paper that interventions which strengthen citizen demand for better services and
345 greater accountability are much more effective if they are carried out strategically, in tandem with efforts that “bolster state capacity to actually respond to citizen voice”
(2014, p. 5). Poli and Guerzovich, in a blog for the Global Partnership for Social
Accountability titled “Are we ready for strategic social accountability?” put forward their views of why promoting government responsiveness is crucial:
In short, although there may not be an exact recipe that guarantees successful social accountability, we have learnt why so many projects fail: Social accountability’s promises have not been fulfilled, in large part, because the technical tools we have been using do not take account of the political nature of accountability processes. Holding public officials accountable is a contested and uncertain process, and therefore ignoring public officials’ incentives poses large risks to the success of a social accountability project. (Poli and Guerzovich 2014)
For Fox, strategic social accountability is much more than reaching out to service providers and government oversight institutions in order to facilitate and promote greater responsiveness. He writes:
“[…] tactical and strategic […]. These two terms warrant explicit definitions. At the most general level, strategies link coordinated actions to goals, with a macro view of the overall process, whereas tactics refer to specific micro-level actions. “Strategic” is defined in this context as an approach with a theory of change that takes into account the relationship between pro-change actions and eventual goals by specifying the multiple links in the causal chain. A “tactical” approach is limited to a specific link in the causal chain.
(Fox 2014, p. 22)
It is striking to what extent the MM/QSC intervention fits the definition of a strategic social accountability. The intervention was comprised of a series of actions (“multiple links”) which all contributed to the same pro-change aim of getting health workers to improve their working practice. What let this intervention down was the fact that there was little or no coordinated action; the implementation plan was revised at the last minute to avoid duplication and to include a component that had been successfully
346 implemented by the same agency in the past. However; the implementation plan changed several times, apparently at the behest of the two field officers, who had little or no technical knowledge but responded to demands from the health workers and citizens (especially with regards to the inclusion of a series of citizen-supported construction project, which some health workers redirected towards the purchase of a generator). This spontaneously added component appears to have led to a decision to not hold any repeat Quality Service Circle meetings. Overall, this intervention had a lot of potential, and came close to being a strategic social accountability intervention, but its execution let it down.
This example stresses better than any other, that there is a need for guidance during the social accountability programme design stage. In order to emphasise the importance of working with the relevant authorities, I believe that the importance of the ‘strategic’ or
‘government responsiveness component’ should be recognised more explicitly. I therefore suggest that it should be included under a separate heading in an analytical framework for social accountability methodologies.
9.3.3 Using the analytical framework for social accountability as a design template
Re-examining the analytical framework to verify whether the most important ingredients for a successful social accountability intervention were selected, leads me to confirm that the four selected components did prove to be of great importance.
However, these components reflect the social accountability literature available around the time this research project started, in 2012. As this chapter has shown, the literature
347 on social accountability contained some significant gaps. The evidence that this research has produced suggests that in future, a new analytical framework for social accountability should include the two additional components identified in this chapter: firstly, ensuring adequate implementation capacity and secondly, stimulating government responsiveness by creating a strategic social accountability intervention.
An enhanced analytical framework for social accountability would therefore look as follows:
1. Redressing information imbalances 2. Citizen participation 3. Power and political awareness 4. Staff motivation 5. Ensuring adequate implementation capacity 6. Strategic collaboration with local/national authorities to stimulate responsiveness
Evidence from this research suggests that the inclusion of all six elements would not only be useful in an analytical framework that can be used to evaluate social accountability interventions after they have been implemented. This framework can be employed at the design stage of any social accountability intervention. I therefore suggest that the framework above should be considered a ‘social accountability design framework’. Using the framework allows designers of social accountability interventions to guide them through pre-implementation research and critically examine their intervention design before it is piloted. The social accountability design framework assists in anticipating where possible contextual challenges may arise, making the need for a ‘context-aware social accountability intervention’ a less nebulous concept, but one that can be produced with the right guidelines and well directed pre-intervention research.
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9.4 Creating a new social accountability model
To demonstrate how all of the six components of a social accountability design framework can be applied in practice, this chapter will conclude with an example of a model social accountability intervention, designed specifically to work within a similar context as the interventions studied for this research:
1) Redressing information imbalances - The model intervention includes both information dissemination as well as an information gathering components. For example, during the first year of the implementation there is a strong citizen engagement component during which citizens and elected Facility Management Committee members receive information regarding the standard of care the health facilities should adhere to, and certain citizen groups’ entitlements to free care.
Health workers receive information and training, during which they are made aware of the standards the government has set for healthcare delivery, and free healthcare entitlements that have been mandated by law.
Staff from the DHMT will also receive training that raises their awareness of existing government standards and policies, and they are involved in the compilation of a ‘basic standards check list’.
2) Power and political awareness - Attention should be paid to the nature and process of engaging citizens to ensure that such engagement is meaningful and not subject elite capture. Throughout the process, oversight will be carried out to check for undue dominance of health workers or DHMT staff in the dialogue process to ensure that real accountability problems are examined and addressed in ways that can lead to the required behaviour change.
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3) Citizen participation – This is the core process of the intervention: In advance of the interface meeting (see 4), skilled facilitators from the implementing CSO conduct one-day fact finding exercises during which different sections of society (separate focus groups with males, females, young, elderly, people with disabilities, etc.). During the fact finding day, ‘the healthcare received in this location’ is evaluated against the standard that is set by government, using the basic standards check list (compiled in advance in collaboration with health workers and DHMT). At the end of the day all evaluations are amalgamated, with the resulting list reflecting ‘what needs to change to ensure everybody in the community can access a minimum standard of healthcare’.
A separate health worker focus group discussion is held in which they are asked to reflect how well they are able to meet the standard of healthcare delivery that is expected of them.
4) Strategic collaboration with local/national authorities to stimulate responsiveness - A joint community, health worker, local health authority interface meeting is held, facilitated by the CSO, to discuss the community and the health workers evaluation of the health facilities. The district authority official leads a joint verification of check list items and desired changes are listed in a community-health worker compact.
Health workers, community and DHMT staff will jointly plan that necessary upgrades will be funded by the clinic’s quarterly maintenance budget, where possible.101 A designated DHMT staff member is appointed as responsible for reporting -and following up on- any significant problems such as broken fridges, unacceptable behaviour, etc., to relevant colleagues at the district health authorities. Community representatives from each of the sections of society are appointed to join the FMC on a monthly monitoring visit to the clinic.
101 This component is inspired by the Ethiopia Social Accountability Program-phase 2. During implementation social accountability methods such as community score cards are used as a mechanism to discuss service standards. Citizen-identified shortcomings are discussed during interface meetings between service providers, district authorities and the community, and at these meetings, part of the Woreda [district] block grant are committed to be spent on service upgrades (Pieterse et al, 2016). 350
A follow-up meeting with the community, health workers and district health representative is conducted three months later. A CSO facilitator checks in with the community representatives and FMC every two months to monitor progress.
5) Staff motivation - A competition for most improved clinic is part of this model. The competition uses the DHMT verified check list scores as the baseline. The prize is an item that can be won for the clinic, such as a motorbike or a solar fridge, plus a cash reward.
A year after the first meeting, the community representatives, health workers and CSO facilitators score clinic improvements against the baseline. A meeting in the district capital brings community, FMC and clinic representatives together to determine the winning clinic and honour the winning health workers and community group.
6) Ensuring adequate implementation capacity: The model social accountability intervention contains a pre-implementation capacity building component, to ensure that implementing agencies have the right capacity to carry out the intervention.
Those who supervise the implementation are also provided with training to ensure that they understand what to monitor. As much as ‘adhering to hiring and procurement procedures and financial management’ is important, supervisors are taught to examine the implementation on additional indicators such as quality (and power balance) of the dialogue during interface meetings and the fairness of the improvement plans.
The intervention described above would be a serious investment in health service improvement, but it is designed in such a way that significant elements can be integrated into the DHMT’s routine M&E practice. 351
The intervention has a strong info-in component, much like that of the PM&E method, which had a delivery method that was hard to improve on. The new model contains a more significant citizen engagement component, which introduces a type of quality service circle meeting, but combines the presentation of the check list information with an opportunity to hear direct feedback from individuals. It also requires the presence of a DHMT staff member who is not just there to leverage the FMC’s power. A designated DHMT staff member should also create all-important feedback loops which can take up community level information (complaints, breakdowns or stock-outs) and ensure that the relevant member of staff deals with it. The inclusion of a discussion around the spending of the PBF component that is earmarked for clinic maintenance should prevent health workers from spending only a portion of this fund and keeping the rest to themselves. The success of such a component is contingent on the regular disbursement of such funds, or even better, a possible de-coupling of performance bonuses and clinic maintenance funding.
9.5 Conclusion
This chapter has provided an evaluation of the four accountability interventions, using the analytical framework that was established after a review of the relevant literature in chapter two and three. The analysis provided evidence that the PM&E intervention was the most successful at achieving its stated aims of ‘improving accountability in the health sector’. Furthermore it was noted that the NFA intervention had also achieved some improvements in health worker behaviour change, making the two ‘competition- based’ interventions the more successful interventions when it came to health worker
352 behaviour change. The MM/QSC method had rather mixed results, achieving significant behaviour change in two out of the ten target clinics, some improvements in another four clinics but no discernible results in the remaining four health facilities.
The analytical framework that was used to compare the four interventions in section
9.1, was judged to contain four relevant components. However, the research suggested that the framework was incomplete. Section 9.2 provided arguments for the inclusion of ‘CSO capacity to implement accountability interventions’ and ‘strategically promoting government responsiveness’. The former was added because the research provided evidence that such capacity can be lacking, which undermines the chances of a social accountability intervention achieving its goals. The latter, ‘strategically promoting government responsiveness’, seems to have contributed to the considerable success of the PM&E intervention. This component was less prominent in the other interventions, but in the selective incidences where staff, implementing the MM/QSC intervention, reached out to local government authorities in order to solve significant accountability challenges, marked improvements in health worker responsiveness were noted. Given the fact that some of the more recent social accountability literature highlights similar findings, I suggest that this component should have a separate heading within a social accountability analytical framework. Section 9.3 suggested that these six components are not just relevant for post-intervention evaluations. These six elements should also be considered as a social accountability design framework:
1. Redressing information imbalances 2. Citizen participation 3. Power and political awareness 4. Staff motivation 5. Ensuring adequate implementation capacity 6. Strategic collaboration with local/national authorities to stimulate responsiveness
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Given that five components are derived from the literature on social accountability and one component is derived from the literature on NGO accountability, I suggest that this is a generalizable design framework that could be applied to social accountability interventions well beyond the sector and geographical location of this research.
This chapter concluded with a model of an ideal type social accountability intervention that contains elements of all of the four interventions examined by this research, plus further elements borrowed from the social accountability literature and my work experience. This model is, as all social accountability interventions should be, specifically designed for the health sector in Sierra Leone ca. 2012 to 2014, and should therefore always be adjusted to the local context if implemented elsewhere.
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Chapter 10 - Conclusions
10.1 Introduction
The past decade and a half has seen the emergence of ‘social accountability’, a concept used primarily within the international development sphere that encompasses a range of interventions which promote greater accountability of service providers towards citizens, usually by supporting citizens (service users) to hold frontline service providers to account for quality basic services to which citizens have a right.
There are many definitions of social accountability: some portray the concept as a catch-all phrase for any kind of intervention in which citizens are able to influence the planning and provision of common goods and services (Malena et al 2004), while other definitions are more narrow. Social accountability is closely linked to the concept of ‘accountability’ within the political and service provision sphere. Acosta et al believe that “[…] a basic notion of accountability refers to both the responsiveness of elected officials to citizens’ demands, and the responsibility that government officials have to act upon those preferences” (2010, p. 5). This includes all the key concepts that social accountability aims for: citizens expressing their preferences and governments being responsive to them.
While the body of literature on social accountability is steadily growing, many specific questions regarding this methodology remain under-researched. These include, for example, queries regarding the efficacy of social accountability methods in challenging operational environments, or the variance in success between several different methodological approaches. This research project has tackled both of these questions 355 by examining a series of social accountability interventions in the health sector in
Sierra Leone.
The research conducted for this thesis examined four different social accountability interventions, all of which used a different method to achieve broadly the same aim: to improve primary healthcare delivery by promoting greater accountability among frontline health workers in rural clinics. The research was guided by the following questions:
(i) Why and when do social accountability interventions aimed at improving public service delivery, succeed or fail?
(ii) What effects do social accountability interventions have on frontline staff in healthcare facilities?
(iii) How can social accountability methodology be improved?
Section 10.2 of this chapter will provide a brief summary of this thesis. In section 10.3 the findings of the research will be used to address the three research questions.
Section 10.4 reminds us of the limitation of social accountability interventions. Section
10.5 outlines the contributions this study has made to the knowledge of social accountability methodology and 10.6 points to implications for further research.
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10.2 Summary of the thesis
This thesis presents the findings from research conducted in the health sector in Sierra
Leone. This paper examines the results of a comparison of the four case studies, the conclusions of which are provided in this chapter.
Chapter one provided the introduction to the study.
Chapter two presented the literature on which this research was based. It gave an overview of the social accountability literature and expanded into two other kinds of literature that were relevant for this study; the literature on corruption and the literature on human resources for health. Based on this extended body of literature, four key components were identified which together formed the analytical framework for the social accountability interventions examined during this study.
Chapter three operationalised the four analytical framework components, gave an overview of the research design and provided details about the challenges encountered during the field research.
Chapter four presented the context in which this research took place: it provided a brief history of Sierra Leone, some details about the country’s historical challenges with public service provision, and its current transition towards a decentralised system.
The chapter also gave an account of the changes within the health sector since the end of the civil war, most notably, the introduction of the Free Healthcare Initiative.
Chapter four concluded with a short examination of Sierra Leone’s civil society and the challenges faced by that sector.
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Chapters five, six, seven and eight presented the four ethnographic case studies that are the focus of this research. They provided details of the four methodologies examined throughout this study: Community Monitoring with Scorecards, Non-
Financial Awards, Participatory Monitoring and Evaluation and Mixed Methods with
Quality Service Circle.
Chapter nine provided an analysis of the four interventions and examined the utility of the analytical framework used for the examination of the four social accountability methodologies. Chapter nine identified two additional components that were equally important for the success of a social accountability and concluded that the following six components should be considered not just an analytical framework, but also a social accountability design framework which can be used to design or evaluate social accountability interventions in a wider context:
1. Redressing information imbalance 2. Citizen Participation 3. Power and political awareness 4. Sustainable staff motivation 5. Ensuring adequate CSO/NGO implementation capacity 6. Strategic collaboration with local/national authorities to stimulate responsiveness
10.3 Addressing the research questions
This research project was guided by three research questions, which will be addressed in turn in this section.
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10.3.1 Why and when do social accountability interventions aimed at improving public service delivery, succeed or fail?
This study has examined four different social accountability methodologies with the aim of establishing what led to the four interventions achieving significantly different outcomes under similar circumstances. Chapter nine confirmed that the four key components selected at the beginning of this study were indeed contributing factors to the success of some, and the relative failure of other, interventions. It also provided evidence that two further components are equally, if not more, important to a social accountability programme’s outcome. Chapter nine concluded that these six components of the expanded analytical framework are generalizable and apply to a much broader range of social accountability interventions targeting a variety of sectors in different operational environments.
I will therefore use the new analytical framework to answer the first question: “why and when social accountability interventions aimed at improving service delivery success or fail?” Evidence from this research suggests that social accountability interventions can succeed when:
1) Relevant information is provided to local communities about their entitlements to a service and about the standards that apply to it. Information might also be gathered about the service provision or the service outcome (i.e. the health status of community, or test results in the education sector) which can be processed and fed back to local communities in order to facilitate a comparison to the existing standards or to other service providers – however, this information needs to be relevant, clear and actionable. Even when an information component is all of the above, it may still not be
359 enough to contribute to a redressing of the power imbalance between citizens and service providers. The research suggests that creating the right opportunity to redress this imbalance may be a key factor in terms of seeing the right information component working as a catalyst. More research is needed to establish if this is a common catalyst/missing link.
2) Citizens are supported to actively engage with the service providers in their locality.
For this to be possible, citizens need to have the right information to hold service providers accountable, and they also need to be made aware of the entry points that exist for them to engage - and of the relevant authorities through which they can resolve disputes that are beyond their remit. Implementing CSOs need to support citizens and citizens groups to overcome collective action problems, by providing practical support and, for example, the facilitation of meetings with district level ministry officials, whose power they can leverage.
3) Power awareness and political awareness are embedded throughout the social accountability intervention and conscious measures are introduced to balance power asymmetries. The endeavour to change accountability relationships between citizens, service providers and local government authorities is inherently political and involves the shifting of power dynamics, which need to be researched in advance and dealt with in a way that recognises the existing incentive structures that may need to be changed in order to sustainably improve service delivery outcomes.
4) Efforts are undertaken to bring about sustainable staff motivation. While there are no motivational formulae that are guaranteed to succeed in all circumstances, this research has highlighted that it is important to bear staff motivation in mind and be cognisant of service providers’ need to be guided towards service improvements they
360 are able to make. Of course all of these measures can only succeed if they are undertaken in a context wherein service providers are in receipt of a regular basic salary and in which their unaccountable behaviour does not stem from the fact that they have no income to survive on.
5) A social accountability intervention works ‘strategically’, which means that it supports citizens to evaluate the services they receive and articulate their need for service improvements. An intervention simultaneously needs to work with service providers, and the authorities that support and supervise these providers, to ensure that these individuals are able to respond to the citizens’ demand for better services, and that the incentive structures are manipulated in such a way that their greater responsiveness is sustained.
6) In order to realise all the above, the CSO or NGO that implements the social accountability intervention needs to have adequate capacity to do so. Capacity, in this context, means the right staff in place who have the relevant qualifications and work experience to understand not only what actions need to be undertaken to implement a social accountability interventions, but also what outcomes are aimed for in terms of service provider behaviour change and transformations in terms of citizen-state interactions. Such staff need to be supported by its employers through training and a salary that reflects the responsibility of the job, which does not tempt any CSO/NGO employee to cut corners within the implementation in order to gain financially. In addition, it is important that an implementing agency has integrity. This is obviously not a quality that can be enhanced through training, but it is something that a contracting agency does need to be aware of. When working with new organisations in countries with high levels of corruption, additional ‘due diligence’ such as thorough
361 reference checking and speaking to other agencies that have worked with the organisation in question, should be standard practice.
In an ideal world district (or other local) level officials would also have sufficient capacity to work with local communities to enhance their ability to demand higher health service standards.
10.3.2 What effects do social accountability interventions have on frontline staff in healthcare facilities?
This question is sector specific, but I believe its answer may also be generalizable beyond the health sector. Social accountability interventions tend to focus on ‘the citizen’ as the user of a public service who can be supported to demand greater accountability from those who provide services. This construction can overlook the actual fact that it is ultimately the service provider whose behaviour change social accountability interventions aim to achieve. If successful, the effect of a social accountability intervention on a service provider can be significant.
As the literature suggested, there are many reasons why a service provider acts in an unaccountable way. Very often, in developing country contexts, low salaries, minimal supervision, and a permissive environment can lead service providers to act unaccountably to improve their situation - in terms of financial gain or the freedom of not working when one should (Barr et al 2004, Ferrinho and Lerberghe 1999, McPake et al 1999). In many cases, service providers also lack the means, in terms of skills or supplies, to meet the standards set for the service they are supposed to provide (Das et al 2012, Mullan et al 2011). When service providers are pressured to become more
362 accountable this often means that they lose some of the benefits they created for themselves by acting unaccountably. However, ‘benefit maximising behaviour’ is not the only type of behaviour service providers display. The literature suggest that the majority of service providers are furthermore motivated by additional incentives: professional pride, peer recognition, the chance of winning a competition, the opportunity to forge better relationships with the community (Brock et al 2012,
Chaudhury et al 2005, Mathauer and Imhoff 2006). There are two ways in which a social accountability intervention can affect a service provider: firstly, it can provide positive incentives such as peer pressure, professional pressure, an opportunity to forge better relationships with the community or it can incentivise improved behaviour by introducing a competition with the objective of motivating a service provider to become more accountable. Secondly, it can also increase negative pressure by strengthening existing oversight mechanisms, which makes it more difficult or less profitable for a service provider to benefit from rent seeking behaviour.
Social accountability interventions work best when the implementing agency, together with the community, and with the engagement of the relevant sector authorities, are jointly able to work in both ways to i) shift the incentive structures to make it less attractive for service providers to act unaccountably, and ii) to ensure that it is within a service provider’s interest to act accountably.
Evidence from the research suggests that health workers in Sierra Leone reacted in a number of different ways to the four interventions they encountered - each of which offered a different shift in incentives. The strongest reaction and most significant behaviour change was triggered by the competition which offered significant prizes, additional peer pressure and supervisor recognition. The competition without a
363 monetary prize still attracted enough interest to confirm that health workers were happy to make a greater effort for ‘respect’ only. Pressure to change through a series of community meetings clearly did not convince many health workers, assumedly as the potential benefits to the health workers were uncertain, at best. When a health worker’s supervisor attended a community-health worker dialogue meeting, the dynamics changed, so when the prospect of negative consequences for acting unaccountably was introduced, health worker responsiveness increased.
In conclusion: the number one objective of any social accountability intervention is to have a positive effect on service providers’ behaviour. The objective for all social accountability interventions is to ensure that it can engender a lasting shift in incentives that creates a context in which service providers are driven to act more accountably and provide better services as a result.
10.3.3 How can social accountability methodology be improved?
The results of this research point in several clear directions; the social accountability design framework identified in chapter nine should be a useful starting point to guide those who are in the process of starting to plan a social accountability intervention.
The response to the first research question (10.3.1) has in effect already answered this question; the evidence suggests that all of the six components are important, even if a particular intervention is designed to focus on top-down monitoring only.
Improved social accountability interventions should be strategic, as Jonathan Fox advocates, and be context aware, as Fletcher Tembo suggests. The design of a social accountability intervention should be holistic. It should take account of power
364 imbalances, information imbalances, the politics - local and national, and all of the external factors that influence service delivery. It should also bear in mind the motivation and the incentives expectations of all the actors: the implementing agency, the relevant authorities and the service using community. With this many factors influencing the outcome of a social accountability intervention, a design should always be iterative. It should be able to respond to what it finds during the implementation.
This does not mean doing a little bit of everything, as the mixed methods intervention demonstrated, but it does mean that the implementers of an intervention should be attuned to small shifts in service provider behaviour and be able to analyse what caused it. There is no one-size-fits-all solution to improving accountability, only a body of literature that is steadily growing, which can offer ever more specific directions regarding what to try and what to avoid. This research has demonstrated that it is impossible to separate practical implementation issues from the higher level political or philosophical ones - as they are inherently linked. What weakens the arguments of many of those who theorise about the political economy or the right fit of social accountability interventions, is that the majority continue to do so from afar, thereby missing the importance of the interaction between the practical and the political, which can undermine the success of social accountability interventions.
10.4 The limits and added value of social accountability interventions
Having answered the three research questions with which this research started, a critical note needs to be added. This research has concentrated on establishing which of the four social accountability interventions was most successful at achieving its 365 goals, and it has further focused on generalizable lessons emerged from this research.
This research also needs to acknowledge the limits and the potential of the methodology, which goes beyond meeting programme objectives.
Social accountability methodologies are often employed for more than just achieving a singular objective. Those agencies who fund or implement social accountability interventions often choose this methodology for the additional benefits that can be accrued in the process of achieving (or attempting to achieve) the stated goals. To reflect this additional quality, the question ‘how can social accountability methodology be improved’ needs to be expanded with a further question: to what end?
While the differences in top-down and bottom-up approaches have been discussed in this thesis, so far there has been little opportunity to raise the issue of the added value of citizen-empowerment through social accountability. As noted in the literature chapter, most social accountability interventions have a strong citizen engagement component for two reasons. Firstly, citizens are often situated closest to a service and are therefore in a great position to obtain service delivery information. Secondly, working with citizens to strengthen their voice and support them to hold service providers accountable can work as an effective way of empowering them (Gaventa and
Barrett 2010, Fiszbein et al 2011). While this second goal cannot always be achieved, as witnessed during this study, it is nevertheless a laudable aim which tends to work more often than it does not (Gaventa and Barrett 2010). Many social accountability interventions are designed to achieve greater accountability, but the focus is as much on the route it takes to get there. McGee and Kroesschell (2013, p. 7) describe these as follows:
[Transparency and Accountability Initiatives] are applied in pursuit of various goals, possibly but not necessarily overlapping. A common characterisation of these is in 366
terms of ‘developmental’, ‘democratic’ and ‘empowerment’ goals. Two or even three of the same kinds of goal might overlap within one TAI; and the TAI’s theory of change might pursue the promotion of one kind as an intermediary goal and another kind as the final goal (e.g. democratic engagement in the pursuit of better service provision, which in itself is a developmental goal) (Malena et al 2004; McGee and Gaventa 2010).
Interventions such as Community Monitoring with Score Cards or Quality Service
Circle, which are focused on community-service provider dialogue, often aim to empower citizen- service users to hold service providers to account. In these cases the
‘means’, which is the community empowerment, is often as important as the ‘end’: greater accountability.
This research revealed that citizen empowerment was greatly lacking in rural Sierra
Leone, as is the case in many other post-conflict environments (Brinkerhoff et al 2012,
Oosterom 2009). The two social accountability interventions that contained the largest citizen engagement component were relatively ineffective in creating greater citizen empowerment, which led to a disappointing lack of impact (McGee and Gaventa
2010). It suggested that citizen engagement does not necessarily lead to citizen empowerment. In the case of the community monitoring intervention, it was clear that the intervention lacked pre-interface engagement which could have empowered the communities by providing the right information, it also lacked good facilitation and by not engaging with the local health authorities, it missed an opportunity to redress the power imbalance during the community-health worker dialogue sessions. It is clear from the CM example, and also from the MM/QSC intervention, that a good programme design and strong implementation capacity are important to ensure citizen empowerment. Even under ideal circumstances it is clear that citizen-engagement focused accountability interventions are extremely difficult to implement successfully in an operational environment such as Sierra Leone.
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Similar challenges have been encountered during the implementation of social accountability in other difficult operational environments such as the eastern DRC, where the Tuungane programme has achieved impressive goals (Ho et al 2015), which were nevertheless limited by the fact that central government was largely unresponsive; or Bangladesh, where elite capture and the dominance of the more powerful citizens and service providers were impossible to counter during a ‘citizen engagement in local government’ intervention (McGee and Kroesschell 2013).
However, in such environments, opening up spaces in which a community can interact with service providers, start to overcome collective action problems or tentatively pressurise authorities on issues of service provision, are often significant and valuable steps forward. Those who are involved in the design of a new social accountability intervention need to be aware of the limits of the social accountability methodology.
As with many other development interventions, the best possible outcome that can be achieved by any given programme is determined by a range of limiting factors. It is incumbent on the designers of an intervention to carry out research in advance which may provide sufficient knowledge of a prospective operational environment, to determine whether or not social accountability is a suitable methodology to achieve the envisaged aims. Some of the most recent writing by Jonathan Fox suggests that social accountability interventions alone may not achieve sufficient change, but he proposes the inclusion of social accountability interventions into a greater range of interventions, which are ‘vertically integrated’, as a way of delivering change at a series of interconnected levels. It acknowledges the limits of social accountability interventions as stand-alone projects, but promotes its use within a wider and more holistic range of interventions that encourage greater accountability throughout a
368 certain sector, from top to bottom. The concept of vertical integration is described as follows:
“vertical integration” of civil society policy monitoring and advocacy […] tries to address power imbalances by emphasizing the coordinated independent oversight of public sector actors at local, subnational, national and transnational levels. The goal is for the whole to be greater than the sum of the parts. The core rationale for monitoring each stage and level of public sector decision-making, non-decision-making and performance is to reveal more precisely not only where the main causes of accountability failures are located, but also their interconnected nature. This focus on understanding as many links in the chain of public sector decisions as possible is relevant both to inform possible solutions and to empower the coalitions needed to promote them.
(Fox and Aceron 2016, p. 4)
This new and potentially enriching conceptual advance appears to be extremely relevant to the accountability challenges in the health sector in Sierra Leone.
References in this thesis regarding the context in which the four interventions were implemented should have made it clear that the accountability issues at health centre level are directly linked to related challenges that can only be addressed at subnational or national level. These issues include the payroll, the health system design, the design of the PBF component of the free healthcare initiative, logistical challenges related to the procurement and delivery of both free healthcare and cost recovery medicine, and the design of the free healthcare policy itself. If a number of these ‘higher level’ policy issues could be tackled in tandem rather than as stand-alone accountability problems, as the proponents of a vertical integration approach propose, I believe that there would be a much larger chance of creating sustainable improvements in the levels of accountability in Sierra Leone’s health sector.
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10.5 Contributions of the study
This examination of four social accountability interventions, which ran concurrently in the same sector in the same country, provides a unique opportunity to learn how, under relatively similar circumstances, four methodologically distinct interventions with the same goal can achieve radically different results. This study makes a contribution to the field of social accountability studies, which are increasingly popular methodologies in the international development arena.
Considering the body of literature on social accountability, it is rare to find a comparative academic study into social accountability methodology that is based on empirical research. Much of the texts on social accountability continue to take the shape of desk-based examinations of reports by non-governmental agencies that have completed a social accountability intervention. Even when empirical studies are carried out to examine the results of social accountability interventions, these are rarely, if ever, of multiple, simultaneous interventions implemented in the same sector and in the same country. This study offers an in-depth comparison of four distinct methodologies which were implemented in a complex operational context.
By conducting an extensive examination of the operational environment in which these interventions took place, it was possible to gain a thorough understanding of prevailing power imbalances and the political economy drivers that operated in the implementation environment. As a result, the study was able to afford not only a technical examination of the four interventions, but also point to where contextual challenges had hampered the implementations. This provided some concrete examples
370 of the need to take ‘contextual drivers of change’ into account in the design of social accountability intervention.
Subjecting a series of ethnographic case studies to analysis with a common framework was a novel approach which produced evidence that may not have otherwise been uncovered. The interventions studied included two cases which were part of a randomised controlled trial and the research was able to demonstrate the limits of the quantative data analysis that was employed throughout the RCT. The use of a mixed range of data sources allowed this study to gain great insights into the workings of each intervention, the findings which were amplified by the cross-case analysis.
The literature on (as well as the practice of) social accountability in challenging operational contexts remains scant, due to its recent emergence as a field of practice. In
2014 Jonathan Fox wrote a seminal paper on social accountability, asking “what does the evidence really say?” He concluded that “more promising results emerge from studies of multi-pronged strategies that encourage enabling environments for collective action and bolster state capacity to actually respond to citizen voice” (2014, p. 5). This study contributes to a growing body of research that confirms Fox’s hypothesis about the amplifying effect that can be achieved by working not only to support citizen voice
(i.e. demand side accountability), but also to stimulate the responsiveness of government to act on citizens’ demands. Evidence from the research suggests that working with government not only helped to improve service providers ability to be more responsive, it often provided a much needed service provider incentive to be responsive to citizens’ demands.
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Having drawn conclusions about the efficacy of social accountability in Sierra Leone, it is clear that lessons have emerged from this research which can also be relevant to broader range of countries and contexts.
At the inception of this research project, a literature review provided evidence that there were no theoretical or analytical frameworks available with which social accountability interventions are commonly assessed. Therefore, at the outset of this study, an analytical framework was created, based on what appeared to be the key components for a successful social accountability intervention.
Evidence from the research has shown that two additional components needed to be added to the analytical framework in order to establish a sound, generalizable framework for the design or evaluation of social accountability interventions.
The new social accountability design/analysis framework is a key outcome of this research, providing structure and guidance to those who intend to design or evaluate social accountability interventions. Given the fact that the interest in the methodology has been growing steadily in recent years (Bannon et al 2012, Carothers 2016), it is hoped that it may be able to contribute to filling the gap that exists between those who are dedicated to furthering the academic debate and refining social accountability practice and those who are in need of practical guidance on how to operationalise recently emerging concepts such as contextual awareness and strategic social accountability.
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10.6 Implications for further research
Sierra Leone is a country that emerged from a brutal civil war in 2002 and has since been on a slow road to recovery. This research has documented how a long and continuous history of corruption at all levels of the state has undermined the country’s political stability and has affected its ability to provide basic public services to its citizens. In 2013 Sierra Leone finally graduated out of the World Bank/African
Development Bank fragile states list (World Bank2013), but the country remains in the bottom ten of the Human Development Index and continues to have the worst rates of maternal mortality worldwide (UNDP 2014).102
Evidence from this research has shown that it is possible to achieve accountability improvements in the primary healthcare sector using social accountability interventions. This achievement is significant for a country with an operational environment as challenging as Sierra Leone. As stated, this is one of the few studies that have examined social accountability interventions in such a context. The positive outcome of at least one of the interventions should inspire more such programmes, and may be able to provide the opportunity for further research into the most effective methodologies to apply in challenging operational environments. This research has pointed to the fact that a methodology that favoured a top-down monitoring approach was more successful than those that were focused on ‘bottom-up’ citizen engagement.
It would be highly desirable if more experiments were carried out with social accountability interventions that contain a strong citizen empowerment component, to enrich practitioners’ knowledge about their efficacy in fragile or conflict affected
102 The post script to this thesis will briefly touch on Ebola, the epidemic engulfed Sierra Leone soon after I completed my field research and its devastating effects on the health sector continue to be felt today. 373 states. It is often places that offer the most challenging operational environments, which need accountability-promoting interventions most (Baird 2010, McGee and
Koesschel 2013).
This study has brought together a practical examination of social accountability interventions with the most recent academic thinking with regards to citizen engagement in the improvement of accountability in basic public services. The results of this study aim to inform future social accountability interventions in challenging operational environments where poor people are most likely to encounter basic services that are substandard and may be out of reach to those who cannot pay. While the objective “making services work for poor people” (World Bank 2004), has not yet been achieved, developing better ways to empower citizens to shift the incentive structures in order to put decent standards services within their reach is an important step in the right direction.
This research showed how social accountability interventions can play a role in improving basic services, even in challenging operation environments. The study also provided evidence of a disconnect between recent social accountability policy developments and the design and implementation of social accountability interventions, which can lead to disappointing programme outcomes. This thesis showed how social accountability programmes that are designed without sufficient contextual awareness and implemented by CSOs that do not have the required competencies can greatly undermine the interventions’ success.
By providing a simple design framework for social accountability interventions, this study aims to assist those who are planning to design social accountability interventions in the future.
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Post script: Ebola
The field research carried out for this thesis was conducted in September 2012;
November 2013 and May 2014. In the run up to the final field trip, it became clear that there had been some Ebola cases in Guinea, close to the border with Sierra Leone.
Given the small and localised nature of previous known Ebola outbreaks (mainly in the
Democratic Republic of Congo), it did not immediately appear to be a reason for cancelling my field research.
As we now know, the Ebola outbreak developed at an unprecedented rate (BBC 2016).
The first case of Ebola in Sierra Leone was confirmed at the end of May and stemmed from a blood sample taken on May 24th 2014 in Kenema town (WHO 2014a). The virus spread rapidly from there, with the earliest wave of infections occurring in
Kailahun and Kenema Districts before spreading to the rest of the country. By the end of 2015, when the outbreak was largely under control, the total death toll from Ebola was close to 4,000 in Sierra Leone (WHO 2016), and over 11,000 in total in the three most affected countries: Liberia, Guinea and Sierra Leone (BBC 2016).
Within weeks of the outbreak taking on alarming proportions, the press coverage, health and humanitarian experts’ commentary started to speculate about the reasons why this particular epidemic was of a scale never seen before. The issue of ‘trust’ was mentioned repeatedly in the narrative about why patients were not accessing health facilities and why the communication between the government, line ministries, health facilities, communities, international donors and humanitarian agencies was so problematic (Ansumana 2014, Farrar and Piot 2014, Fustukian and Cavanaugh 2014,
International Crisis Group 2015).
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Having conducted research in rural health facilities in Sierra Leone up until the 16th of
May 2014, I realised that I should share my findings and my impressions about Sierra
Leone’s primary health sector and the health worker - community relationships I had encountered. In the introduction of the article I published (along with Professor Tom
Lodge), the findings are summed up as follows:
A lack of accountability in Sierra Leone’s health sector appears pervasive at all levels. Petty corruption is rife. Understaffing leads to charging for free care in order to pay clinic-based ‘volunteers’ who function as vaccinators, health workers and birth attendants. Accountability interventions were found to have little impact on healthworker (mis)behaviour (Pieterse and Lodge 2015, p.1)
Two years after the first Ebola infections, there is a little more clarity about what happened in Sierra Leone and neighbouring Liberia and Guinea at the time the countries were in the midst of the crisis. While there are dozens of stories of heroic acts, there are sadly also many accounts of instances of corruption, opportunism and a lack of accountability at all levels. A report by the International Crisis Group noted:
Ebola “business” came to refer to ways to obtain money meant to halt the epidemic. Guinean authorities no longer accuse international NGOs of opportunistic fundraising, but some predatory local NGOs emerged. Sensitisation activities were particularly open to abuse, as many phantom organisations registered with the national Ebola coordination agency. (International Crisis Group, pp. 13-14)
While it is impossible to quantify, it is almost certain that a number of people lost their lives when Ebola sensitisation that did not happen because the implementing agency was fraudulent. Patients did not receive the care they needed because the additional health workers’ salaries paid by the government and donors disappeared into the pockets of embezzling local health authority staff.
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The governments of the three affected countries have come under great pressure to account for the funds they received during the crisis. The Sierra Leone Anti-Corruption
Commission published its findings in February 2015. “With the February 2015 publication of an audit report on management of Ebola funds between May and
October 2014, Sierra Leone has gone farthest” the International Crisis Group report suggests, noting further that: “[…] about US$14 million could not be accounted for and raised questions about some senior officials who managed the epidemic, civil society leaders and contractors” (2015, p.14). Among the high profile alleged Ebola fund embezzlers were a District Medical Officer, the director of financial resources of the Ministry or Health and Sanitation and Charles Mambu, the founder and director of
Health for All Coalition (Sierra Leone Anti-Corruption Commission 2015).
Among the more positive stories that emerged after the worst of the Ebola epidemic was over, was the story of how Kailahun District “kicked Ebola out”. The most successful social accountability intervention examined during my research project was implemented by SEND Foundation throughout the entire District of Kailahun. SEND’s intervention focused heavily on working with the District Health Management Team and created a strong working relationship between the local health authorities, and local and international NGOs that were operational in Kailahun. The positive working relationship was such a help to the smooth implementation of the crisis management in the early days of the Ebola outbreak, which several authors remarked upon, including one in a World Health Organisation blog post from December 2014:
There were good interpersonal relationships between all the players including the District Medical Health Teams, WHO, MSF, Save the Children, World Vision, UNFPA and, importantly, the local nongovernmental organizations,” says Dr Victoria Mukasa, WHO Infection Prevention and Control specialist, who spent more than 2 months in [Kailahun] District. (World Health Organisation 2014c)
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All three affected countries now face considerable challenges in terms of rebuilding their health systems. Ebola caused a disproportionate number of deaths among health workers, who were exposed to the virus unknowingly at times, or without sufficient protection. The number of Ebola deaths among healthcare personnel is thought to have reduced the number of practicing doctors in Sierra Leone by 5% (due to the deaths of
12 of the pre-Ebola total of 220 doctors in the entire country) and caused a 7% reduction in nurses and midwives (Evans 2015, WHO 2016). Given that these losses occurred in countries that already faced serious staff shortages in the health sector, it is feared that the deaths of so many health workers may lead to Sierra Leone, Liberia, and, to a lesser extent Guinea, struggling to provide basic health services for some time to come:
The paper estimates how the loss of health care workers to Ebola will likely affect non-Ebola mortality even after the disease is eliminated. It then estimates the size of the resource gap that needs to be filled to avoid these deaths, and to reach the minimum thresholds of health coverage described in the Millennium Development Goals. Maternal mortality could increase by 38 percent in Guinea, 74 percent in Sierra Leone, and 111 percent in Liberia due to the reduction in health personnel caused by the epidemic. (Evans et al 2015, p. ii)
Research conducted in the past twelve months (Dziewanski 2015, Kilmarx et al 2014) show that the Ebola epidemic has already had a detrimental effect on reproductive, maternal, newborn and child (RMNAC) health outcomes, with one report estimating:
Comparing modelled RMNAC health outcomes in the current Ebola outbreak to a hypothetical situation without Ebola, we found there would be an average of 22% more maternal deaths and 25% more newborn deaths in Sierra Leone over the year May 2014 - April 2015.
(Ministry of Health and Sanitation/ DIFD/Irish Aid/UNFPA 2015, p. 21)
The same report further noted that “Health providers’ fear is resulting in desertion of already understaffed health facilities or limiting the standard of care provided to
380 patients, particularly women in labour” and “Health staff often lack adequate protection and training in infection prevention control (IPC) and Ebola case management” (2015, p. iii).
Given that the above mentioned articles and studies do not mention the informal workers who were found to support the official health facility staff at every clinic where I conducted research, one can only guess what has really been happening to the entire healthcare providing community (counting both formal and informal staff). It can be assumed that if a significant number of those who were official staff on payroll have deserted their work duties out of fear of contracting Ebola, it is likely that those who were ‘volunteers’ at clinics did so in ever greater numbers. It would be useful to see research being conducted into the role that healthcare volunteers and TBAs played during the Ebola crisis and afterwards. The existence of a significant cadre of unofficial healthcare staff was a direct result of the post-war demand outstripping the official supply for health workers throughout Sierra Leone (Amnesty International
2009). As the country is faced with a new health worker gap, it will be interesting to see if it too will be filled with ‘volunteers’, or if the Ebola crisis has irreversibly altered people’s perception of ‘volunteer health work’ as an income generating opportunity.
Whether Sierra Leone, its donors and supporters can ensure ‘not to waste a good crisis’ remains to be seen. While there have been calls to rebuild the country’s shattered health infrastructure (Wall Street Journal 2015, WHO 2015, World Bank 2016), it has been remarkably quiet in terms of the debate around the Free Healthcare Initiative and the Performance Based Finance facility. While the FHCI was credited, in part, with doubling the percentage of births that take place in a health facility (from 25% recorded in the 2008 Demographic and Health Survey to 54% recorded in the 2013
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DHS), increased access and use of ante- and post-natal care and an increased uptake of contraceptives (MoHS/DFID/IA/UNFPA p. 1), the Ebola crisis exposed the many weaknesses of Sierra Leone’s health system - it is unclear who will be taking the lead on the strengthening and /or redesign of Sierra Leone’s post-Ebola healthcare system.
Given the evidence that this study uncovered, one can only hope that a certain amount of redesign will be considered: top-down monitoring and accountability need to be at the heart of any improved healthcare system, as should a recognition of how rural clinics function; they are not run by a single person, stipends and training should be made available to ensure that unpaid and untrained volunteers do not provide the majority of Sierra Leone’s healthcare services. Adding staff to the payroll should be prioritised over making funds available so that health workers can pass on small stipends to individuals who play key, but unpaid, roles in rural clinics.
The Ebola crisis briefly made the world leaders aware of the threat that a single country’s weak health system can pose to the health and wellbeing of the rest of the world (Torjesen 2014). Time will tell whether this awareness will remain at the forefront of people’s minds when allocating sustained donor funding and healthcare expertise to the reconstruction of Ebola affected health systems.
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Appendices
Appendix A1 - Health worker interview guidelines
Interview guidelines- Health Worker Interviews - Draft 2-Sept 2013
*Explain purpose of study, anonymity, possibility to opt out at any time, sign consent form*
Note: Name of PHU, location (village, chiefdom, district) Type of PHU What intervention (NGO, method) Total amount of staff at PHU (assigned, actually present at time of interview)
1-Introductory questions: How long have you worked at this PHU How long in this job Job title How many other locations have you worked Do you have free staff accommodation
2-Work before/after FHCI, continuing constraints: What are changes since introduction of FHCI Changes in work load Overall perceive FHCI positive or negative-why Currently, do you experience: Difficulties faced at work related to pay (payment on time, performance based pay, PHU allocation) Difficulties faced at work related to condition Do you experience inability to perform duties due to drug shortages Do you experience inability to perform duties due to lack of training 2.1 Oversight How often do you get oversight visits from DHMT Do you received other monitoring visits (Health for All Coalition, others) Is there an active facility management committee or other health user group involved with this PHU What do they check Are any of these monitoring visits helping you to do your job better, do you get pos/neg feedback during visit, afterwards (which ones)
3-Involvement with monitoring project What interventions did you notice What interventions were you directly involved in How did you find this project overall Did you feel the project understood your point of view (as a health worker) Did project change your relationship with community Did the project change anything else If yes, is this change good or bad 3.1 Behaviour change Did the project change your behaviour in any way If yes, why and how do you think you changed your behaviour Did the project change behaviour of colleagues, if yes, how and why Did the project change behaviour of community, if yes, how and why 413
Did the project change behaviour of DHMT, if yes, how and why Has this project changed your relationship with DHMT in any way, if yes, how and why If yes, do you think this change will last, or is only temporarily 3.2 Perception of NGO bias, legitimacy Do you feel the organisation is helping you, helping community, or both Do you feel any problems between people and PHU could have been solved better, easier, or maybe not at all, without help of this organisation 3.3 Information about PHU Some projects give community members more information about PHU, such as how many staff should be here, how often should PHU be open – did they give info here, have you noticed community using this info, how do you feel about community knowing such information
4-Motivation What motivated you to choose this job Do you feel that your motivation to perform this job well has changed since you started Has there been any change in motivation since the FHCI Has there been any change in your motivation since the monitoring project What, would you say, is most motivating about your job [Check all motivating factors not yet mentioned] pay, conditions, relationship w community, training, oversight DHMT Has motivation changed due to monitoring project If yes, can you explain what has contributed to your change in motivation 4.1 Compensation Some monitoring projects give compensation for people’s involvement in project, did this project offer any compensation to participants? Did you receive any compensation [If yes to either] Do you think that people will continue with monitoring, community meetings (depending on project) when these compensations are no longer offered
5-Accountability problems The project was started because in some PHUs there were problems such as patients being charged for free services, patients being charged for free drugs, patients were charged for ante- natal check-up cards, patients pay to skip queue, health workers were not at the PHU when they were supposed to, free drugs were given to drug peddlers to sell in drug shops…
Do you think any of these problems still exist Have you experienced these problems yourself Have these problems increased or decreased recently (generally/personal experience of…) Problems increase/decrease since FHCI Problems increase/decrease since project Do such problems affect your motivation to work In what way has monitoring project affected these problems Has project given you a chance to help to change the situation in this PHU
6-Final questions Thinking about all we have discussed, can you think of a way in which the monitoring project could be improved to tackle the problems we discussed Could the monitoring project be improved to give you more motivation to work- in what way
Do you have any questions for me
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Appendix A2 - Interview guidelines Focus Group Discussion (final draft)
Interview guidelines- Community Focus groups - Draft 3-April 2014
*Explain purpose of study, anonymity, possibility to opt out at any time, sign consent form*
Note: Group size and composition Location (village, chiefdom, district) Name of nearest PHU NGO involved and methodology
1-Introductory: Type of PHU Total amount of staff at PHU (are they usually available most days) Free accommodation for staff
2-Experience of healthcare provision under FHCI, compared to before The free healthcare policy was introduced in 2010, how has it changed your local PHU Can you describe how it was before, was anything better than now Have there been any changes in health worker behaviour before/after FHCI
2.1 Charging: Do you pay for Ante natal cards, vaccination cards , additional charges after you have that card, sick child, quantities of medicine, price of delivery at clinic? HOW MUCH? Where do women deliver their babies, at home or at clinic? What changes since FHCI and why? -If charges are revealed, ask how the nurse explains these charges, what are reasons for it? -What is the solution to the problem of charging for free healthcare?
3-NMJD project What interventions did you notice 3.1 Participation, legitimacy What interventions were you directly involved in Did the project change anything If yes, is this change good or bad 3.2 Behaviour change Did the project change your behaviour in any way, why Did the project change behaviour of health workers, if yes, how and why If yes, do you think this change will last, or is only temporarily 3.3 Empowerment If you feel you have helped to improve the healthcare that this community can get through this project, does that also want to make you change other situations in community
4 Official PHU supervision The DHMT is supposed to check on the PHU to see if it performs well, do you notice DHMT checking Instead of the DHMT, [NGO name] provided this monitoring project, what do you think about that How about the Facility Management Committee, Village Health Committee, 5-man committee? Do you think more monitoring is necessary 415
5-Final questions Thinking about all we have discussed, can you think of a way in which the monitoring project could be improved to tackle the problems we discussed Could the monitoring project be improved to improve the health workers’ motivation to work- in what way?
Do you have any questions for me
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Appendix A3 - Focus Group Discussion guidelines (first draft)
Interview guidelines- Community Focus groups - Draft 1-Sept 2013
*Explain purpose of study, anonymity, possibility to opt out at any time, sign consent form*
Note: Group size and composition Location (village, chiefdom, district) Name of nearest PHU NGO involved and methodology
1-Introductory: Type of PHU Total amount of staff at PHU (are they usually available most days) Free accommodation for staff
2-Experience of healthcare provision under FHCI, compared to before The free healthcare policy was introduced in 2010, how has it changed your local PHU Can you describe how it was before, was anything better than now Have there been any changes in health worker behaviour before/after FHCI
3-Monitoring project What interventions did you notice 3.1 Participation, legitimacy What interventions were you directly involved in Was everybody in community informed, could everybody take part Was there a reason why you/somebody could not participate How did you find this project overall Did the project change anything If yes, is this change good or bad 3.2 Behaviour change Did the project change your behaviour in any way If yes, why do you think you changed your behaviour Did the project change behaviour of community, if yes, how and why Did the project change behaviour of health workers, if yes, how and why If yes, do you think this change will last, or is only temporarily 3.3 Empowerment If you feel you have helped to improve the healthcare that this community can get through this project, does that also want to make you change other situations in community If yes, do you think you can do this by yourselves (community) Or need outside help (if yes, how will you get help) 3.4 Information Some monitoring projects give communities information about PHU that they did not know before, like how many people should be working here, how often PHU should be open, did you receive information like this? If yes, did this information help you or community in any way [if pos answer above, follow on] In this case, the organisation gave you this information, do you think you can find out this information easily yourselves, as individuals, community? If so, how would you find out? 3.5 Compensation Some monitoring projects give compensation for people’s involvement in project, did this project offer any to participants? 417
Did you receive any compensation [If yes to either], do you think that people will continue with monitoring, community meetings (depending on project) when these compensations are no longer offered
4-Accountability problems The project was started because in some PHUs there were problems such as patients being charged for free services, patients being charged for free drugs, patients were charged for ante- natal check-up cards, patients pay to skip queue, health workers were not at the PHU when they were supposed to, free drugs were given to drug peddlers to sell in drug shops… Do you think any of these problems still exist (generally/in nearest PHU) Have you experienced these problems yourself Have these problems increased or decreased recently (generally/personal experience of…) Problem increase/decrease since FHCI Problem increase/decrease since project In what way has monitoring project affected these problems - which ones have remained, which ones reduced/ got worse 4.1 Official PHU supervision The DHMT is supposed to check on the PHU to see if it performs well, do you notice DHMT checking regularly Instead of the DHMT, [NGO name] provided this monitoring project, what do you think about that Do you think more monitoring is necessary
5-Staff motivation The health workers in Sierra Leone may sometimes find it hard to do their job well, sometimes their payments are late, they are expected to help people but don’t always have the right medicine, sometimes housing can be a problem, etc Do you think the health workers in your local PHU face such problems Do you think it may affect their motivation to work Do you think the monitoring project has had an effect on their motivation Has the monitoring project changed the relationship between health workers and community If yes, in what way and why do you think that
6-Final questions Thinking about all we have discussed, can you think of a way in which the monitoring project could be improved to tackle the problems we discussed Could the monitoring project be improved to improve the health workers’ motivation to work- in what way
Do you have any questions for me
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Appendix B – Interview and Focus Group Discussion reference codes
Type of interview/name Type on Date of Ref Code Location interviewee intervention interview /FGDs Key Inf: Siapha Kamara, Director, 04/11/2012 KI001 Freetown SEND Key Inf: Sia Foyo, Health for All 06/11/2012 KI002 Koidu Coalition HW01 Kailahun Health Worker in Charge PM&E 11/11/2013 FGD02 Kailahun Focus Group Discussion PM&E 11/11/2013 Key Inf: Dr. Bome, District Medical 11/11/2013 KI03 Kailahun Officer, Kailahun n/a HW04 Kailahun Health Worker in Charge PM&E 12/11/2013 FGD05 Kailahun Focus Group Discussion PM&E 12/11/2013 TBA06 Kailahun Traditional Birth Attendant PM&E 12/11/2013 HW07 Kailahun Health Worker in Charge PM&E 12/11/2013 FGD08 Kailahun Focus Group Discussion PM&E 12/11/2013 TBA09 Kailahun Traditional Birth Attendant PM&E 12/11/2013 HW10 Kailahun Health Worker in Charge PM&E 13/11/2013 FGD11 Kailahun Focus Group Discussion PM&E 13/11/2013 TBA12 Kailahun Traditional Birth Attendant PM&E 13/11/2013 HW13 Kailahun Health Worker in Charge PM&E 13/11/2013 MCHA14 Kailahun MCH Aide PM&E 13/11/2013 FGD15 Kailahun Focus Group Discussion PM&E 13/11/2013 FMC16 Kailahun Facility Management Committee PM&E 13/11/2013 HW17 Kailahun Health Worker in Charge PM&E 14/11/2013 FGD18 Kailahun Focus Group Discussion PM&E 14/11/2013 TBA19 Kailahun Traditional Birth Attendant PM&E 14/11/2013 Key Inf: Mr Jomoh, CRS, former 14/11/2013 KI20 Kailahun TBA QSC programme manager n/a KI21 Kailahun Key Informant n/a 14/11/2013 MCHA22 Kailahun MCH aide PM&E 14/11/2013 FGD23 Kailahun Focus Group Discussion PM&E 14/11/2013 HW24 Kailahun Health Worker in Charge PM&E 14/11/2013 FMC25 Kailahun Facility Management Committee PM&E 14/11/2013 Key Informant- Mr Mambu, DHMT 14/11/2013 KI26 Kailahun Zonal Oversight Officer n/a HW27 Kailahun Health Worker in Charge PM&E 15/11/2013 FGD28 Kailahun Focus Group Discussion PM&E 15/11/2013 TBA29 Kailahun Traditional Birth Attendant PM&E 15/11/2013 Mohamed Osman, SEND SL 16/11/2013 KI30 Kailahun Country Programme Director PM&E HW31 Tonkolili Health Worker in Charge-1 CM 19/11/2013 FGD32 Tonkolili Focus Group Discussion CM 19/11/2013 HW33 Tonkolili Health Worker in Charge-2 CM 19/11/2013 FGD34 Tonkolili Focus Group Discussion CM 19/11/2013 FMC35 Tonkolili Facility Management Committee Control 20/11/2013 FGD36 Tonkolili Focus Group Discussion Control 20/11/2013 HW37 Tonkolili Health Worker in Charge-2 Control 20/11/2013 FMC38 Tonkolili Facility Management Committee Control 20/11/2013 FGD39 Tonkolili Focus Group Discussion Control 20/11/2013
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HW40 Tonkolili Health Worker in Charge-1 NFA 20/11/2013 FGD41 Tonkolili Focus Group Discussion NFA 20/11/2013 HW42 Tonkolili Health Worker in Charge-2 NFA 20/11/2013 FMC43 Tonkolili Facility Management Committee NFA 20/11/2013 FGD44 Tonkolili Focus Group Discussion NFA 20/11/2013 FGD45 Tonkolili Focus Group Discussion Control 21/11/2013 HW46 Tonkolili Health Worker in Charge-3 Control 21/11/2013 HW47 Tonkolili Health Worker in Charge-3 NFA 21/11/2013 FGD48 Tonkolili Focus Group Discussion NFA 21/11/2013 HW49 Tonkolili Health Worker in Charge-3 CM 21/11/2013 FGD50 Tonkolili Focus Group Discussion CM 21/11/2013 HW51 Tonkolili Health Worker in Charge-4 CM 22/11/2013 FGD53 Tonkolili Focus Group Discussion CM 22/11/2013 HW54 Tonkolili Health Worker in Charge-4 NFA 22/11/2013 FGD55 Tonkolili Focus Group Discussion NFA 22/11/2013 HW56 Tonkolili Health Worker in Charge-5 CM 23/11/2013 FGD57 Tonkolili Focus Group Discussion CM 23/11/2013 HW58 Tonkolili Health Worker in Charge-4 Control 23/11/2013 FGD59 Tonkolili Focus Group Discussion Control 23/11/2013 HW60 Tonkolili Health Worker in Charge-5 Control 26/11/2013 HW61 Tonkolili Health Worker in Charge-6 CM 26/11/2013 FGD62 Tonkolili Focus Group Discussion CM 26/11/2013 recording 63 Interview in wrong catchment cancelled FGD64 Tonkolili Focus Group Discussion Control 26/11/2013 Key Inf: Ahmed Muckson, Director 26/11/2013 KI65 Tonkolili of OPARD n/a HW66 Tonkolili Health Worker in Charge-6 Control 27/11/2013 FGD67 Tonkolili Focus Group Discussion Control 27/11/2013 Health Worker in Charge (not 27/11/2013 HW68 Tonkolili recorded)-5 NFA FGD69 Tonkolili Focus Group Discussion NFA 27/11/2013 FGD70 Tonkolili Focus Group Discussion NFA 27/11/2013 HW71 Tonkolili Health Worker in Charge-6 NFA 27/11/2013 Key Inf: Dr Brima Osaio Kamara, 28/11/2013 KI72 Tonkolili DMO, Tonkolili District n/a Key Inf: District Sister Kadiatu 28/11/2013 KI73 Tonkolili Kamara n/a Key Inf: Health for All Coalition 28/11/2013 KI74 Tonkolili Mohamed Hassan Konte n/a Key Inf: Aiah Sam DHMT Social 28/11/2013 Mobilisation Officer + COBTRIP KI75 Tonkolili Director n/a Key Inf: Concern health Officer 28/11/2013 KI76 Tonkolili Rosemary Davis n/a Key Inf: Marianne Byrne, Country 29/11/2013 KI77 Freetown Director of Concern Theresa, NMJD programme 4/5/2014 KI78 Kono assistant Alusaine Koroma, NMJD MM/QSC 4/5/2014 KI79 Kono programme manager FMC80 Kono FMC(CHMVG) MM/QSC 5/5/2014 FGD81 Kono Focus Group Discussion MM/QSC 5/5/2014 420
FMC82 Kono FMC(CHMVG) MM/QSC 5/5/2014 FGD83 Kono Focus Group Discussion MM/QSC 5/5/2014 HW84 Kono Health Worker in Charge MM/QSC 5/5/2014 FMC85 Kono FMC(CHMVG) MM/QSC 6/5/2014 FGD86 Kono Focus Group Discussion MM/QSC 6/5/2014 FMC87 Kono FMC(CHMVG) MM/QSC 6/5/2014 HW88 Kono Health Worker in Charge MM/QSC 6/5/2014 FGD89 Kono Focus Group Discussion MM/QSC 6/5/2014 Key Inf-Patrick Mansaray, Health 6/5/2014 KI90 Kono Alert Kono n/a FGD91 Kono Focus Group Discussion MM/QSC 7/5/2014 FMC92 Kono FMC(CHMVG) MM/QSC 7/5/2014 HW93 Kono Health Worker in Charge MM/QSC 7/5/2014 KI94 Kono Key Inf -District Council Meeting 7/5/2014 FGD95 Kono Focus Group Discussion MM/QSC 8/5/2014 FMC96 Kono FMC(CHMVG) MM/QSC 8/5/2014 FGD97 Kono Focus Group Discussion MM/QSC 8/5/2014 FMC98 Kono FMC(CHMVG) MM/QSC 8/5/2014 KI99 Kono Key Inf Ngungou M&E, DHMT n/a 8/5/2014 Key Inf, Elisabeth Tucker district 8/5/2014 KI100 Kono nurse, DHMT n/a FGD102 Kono Focus Group Discussion MM/QSC 8/5/2014 FMC103 Kono FMC(CHMVG) MM/QSC 9/5/2014 HW104 Kono Health Worker in Charge MM/QSC 9/5/2014 FMC105 Kono FMC(CHMVG) MM/QSC 9/5/2014 FGD106 Kono Focus Group Discussion MM/QSC 9/5/2014 HW107 Kono Health Worker in Charge MM/QSC 9/5/2014 Key Inf, Lahai Bockarie, Health for 9/5/2014 KI108 Kono All Coalition, Kono n/a KI110 Key Inf-Paula Molloy, Irish Aid 11/5/2014 Freetown Freetown n/a Key Inf-Augustine Allieu, Plan Int, 12/5/2014 KI111 Freetown Freetown n/a Key Inf-Dr Sarian Kamara-MoHS- 12/5/2014 KI112 Freetown deputy chief of policy n/a KI113 Freetown Key Inf-Sue Clark, Director IRC n/a 12/5/2014 Key Inf-Dr Jacob Mufunda, WHO 13/5/2014 KI114 Freetown country rep n/a Key Inf-Yaboh T Sesay Koroma- 13/5/2014 KI115 Freetown presidential advisor on health n/a Key Inf-UNDP S Mukerjee, 14/5/2014 KI116 Freetown director+ EM Kamara, governance n/a Key Inf-UNICEF Dr Yaron 14/5/2014 KI117 Freetown Wolman, Child survival specialist n/a Key Inf-Dr Brima Kargbo, MoHS, 15/5/2014 KI118 Freetown Chief Medical Officer n/a Key Inf- Dr Momodu Sesay, MoHS, 15/5/2014 KI119 Freetown Chief primary healthcare n/a Feedback workshop, Irish Aid 16/5/2014 KI120 Freetown office, Freetown n/a KI212 Freetown Nicholas Menzies, World Bank 16/5/2014
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Appendix C1 - Schedule of completed feedback sessions - to research participants, NGO, CSO staff, and others - provided through meetings, debriefings and reports
Date of Format/location: In attendance: Feedback related feedback session/ to: report: Sept 2012 Meeting w senior SEND country director + SEND’s staff, Freetown (FT) head of programmes programme visited in Sept 2012 Sept 2012 Meeting w senior NMJD country director + NMJD staff, NMJD office, head of programmes programmes, FT redesign of proposal Sept 2012 Meeting w staff, Christian Aid country Scoping visit, Christian Aid office, director, senior and change of NMJD FT governance programme proposal staff Nov 2013 Meeting w SEND SEND programme director Findings of data staff, in car, gathering visit to Kailahun-FT SEND programmes Nov 2013 Two meetings w TNK: head of programmes, Findings of data Concern field + TNK, health advisor. FT: gathering visit to senior staff, Concern Concern country director + Concern offices, Tonkolili deputy, programme staff programmes (TNK) + FT Jan 2014 Report on Concern- n/a n/a supported accountability programmes May 2014 Meeting w NMJD NMJD staff, District Health Findings of data staff + stakeholders, Management Team, heads gathering visit to NMJD office, Kono of clinics, community NMJD programmes monitors, local councillor for health May 2014 Briefing at State Briefing with three senior Briefing on House, FT presidential advisors on findings of my health research in relation to health sector reform May 2014 Dedicated feedback Staff of: Irish Aid, World A roundup of session for all Bank, Christian Aid, findings from the stakeholders, Irish Concern, SEND, NMJD, entire research Aid office, FT MamaYe, and Plan period International June 2014 Report on findings Disseminated to all from entire field attendants422 of feedback research period sessions and key informant interviewees via email Appendix C2 - Opportunities taken to disseminate research findings to wider audience (workshops, conferences, etc.)
Date Event Attendance Notes
11-12 Governance, Attendance of 100+ people Opportunity to share June Accountability And over 2 days, targeting Irish my research findings 2014 Citizen academics, NGO staff, and hear presentations Empowerment: A donors. Attended by from other Learning Workshop: keynote speakers Alina programmes and Christian Rocha Menocal and countries on the Aid/Trócaire/UL Fletcher Tembo, with guest successes and practical event in Dublin contributors: Siapha challenges of citizen Kamara, SEND, Joseph feedback and citizen Ayamga, Governance empowerment Advisor CA-SL, ESAP2 programmes. staff, Ethiopia, and citizen feedback programme staff from Uganda and El Salvador 12-13 Global Partnership 250+ Social accountability Opportunity to share May for Social practitioners and World my research findings 2015 Accountability at Bank staff during a break out World Bank, session on Social Washington DC Accountability offices interventions in the health sector. 19-20 Development Studies 150 Irish international Joint presentation with Nov Association Ireland- development scholars and Alix Tiernan, Christian 2015 Dublin practitioners. Aid: Paper focused on the collaborative research I conducted with CAI. 5-7 World Humanitarian 200+ International Convened panel on March Studies Conference, humanitarian practitioners citizen feedback in 2016 Addis Ababa. and academics. fragile and conflict affected states, presented research paper.
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Appendix D- NVIVO10 Final coding matrix
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Appendix E: Sample of SEND Foundation’s PM&E questionnaire –MDG award survey (pages 1-8)
1. Name of PHU Verification and Scoring Instructions: *Write Please verify the presence of any item 2. Location (Town, Chiefdom) listed in the verification column and place *Write a tick in the “Tick” column if present. 3. Geographical Catchment Area: villages, Please write a score on the score line…. borders, etc. Note: Scores are only required where *Write brief description indicated by a bold line. There may be some items to verify that do not need to be scored. 4. Days and Hours of Mon. Tues. Wed Thurs. Fri. Sat. Sun. Verification Tick Score Operation Open 24 hours (?) *Write hours under each day Hours of operation are publically displayed 5. Services Provided Tick if List of services is publically available displayed *Tick all that apply Routine maternal & newborn care Tetanus toxoid Mebendazole (de-wormer) BP machine and stethoscope Manage complications of pregnancy (CHC) Manual vacuum aspirator *(CHC) Referral guidelines – list of danger signs in pregnancy Supervision of labour and childbirth Oxytocin Delivery kits & cord ties Delivery bed and linen PMTCT (HIV transmission) Postnatal care and counselling Vitamin A
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Iron and folic acid Birth spacing educational materials Family Planning Condoms (male & female) Oral hormonal contraceptives Educational materials on reproductive health Child growth monitoring & nutrition Growth monitoring charts Weighing scale Promotion of early and exclusive breastfeeding Multi vitamins Immunization A.D. syringes Pentavalent vaccine Polio vaccine Measles vaccine Statistics on immunization coverage Integrated management of childhood illness Oral rehydration salt Zinc tablets Albendazole Antibiotics (amoxycillin, ampicillin, penicillin) Tuberculosis BCG vaccine DOTs patient records*(CHC) Malaria Artsenuate combination drugs RDT kits for malaria Insecticide-treated bednets HIV/AIDS & Sexually Transmitted Infections HIV test kits 430
Anti-Retroviral drugs RPR tests for syphilis Health education IEC/BCC Flip charts, posters, and models Reports on IEC/BCC activities Mental health services Chlorpromazine supply Contact information for social workers Register of people on long-term medication for a mental health condition Emergency Health Anaphylactics (promethazine, chlorpheniramine, etc.) Anticonvulsants (Mg sulfate, phenobarbital, etc. Ambo-bag breather Eye care Ivermectin (for river blindness)* Mectizan tablets IEC/BCC on prevention of blindness ENT & Audiology Services Simple test for hearing loss guidelines Aural toilet & wick insertion equipment Epidemic monitoring Monthly Reportable Disease reports Environmental sanitation Draining system for PHU grounds (no standing water) Safe storage for drinking water Safe excreta disposal *(?)Supervision of other PHUs in the chiefdom List of PHUs under supervision 431
with contact number Register of patients referred from other PHU facilities 6. Do you provide laboratory services? No *Tick one Yes Microscope and stains Laboratory space HIV test kits Pregnancy tests RDT kits for malaria 7. Do you provide outreach services to villages No and communities in your catchment area? Yes *Tick one 8. What outreach services do you Immunization provide? s
Tick all that apply Surveillance of reportable diseases
Maternal Reports on outreach activities health Family planning Nutrition Hygiene & Sanitation Other: 9. Is there an ambulance available for No
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emergency medical use for referral to the Yes hospital? *Tick one 10. How many staff (male and female) Position Required Actual # do you have in each position? *BPEHS M F CHO *Record the number of staff in each EHO position by male and female. SECHN Midwife SECHN/CHA Dispenser EDCU Assistant Lab Technician Lab Assistant MCH Aides CHA Vaccinator Medical Statistical Assistant Porter/cleaner Compare actual staffing level Security with legislated levels (i.e. MCHP = 6, CHP = 9,
Other: CHC = 14)
11. Which of your staff are on the Position Payroll Volunteer Posted and government payroll, which are not paid volunteers, and which are unpaid CHO workers? CHA MCHA SECHN
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EHO *Record the number of staff in each EDCUA/Vaccina position who are on government tor payroll, volunteers, or unpaid Porter workers. Cleaner Security Other:
12. Do you have a staff attendance register? No *Tick one Yes Staff Attendance register 13. Is the number of staff signed into the No register the same as the number who are Yes Numbers in Staff Attendance present and on duty? *Tick one register A. WATER AND POWER 14. What is the source of your water? Hand dug well *Tick all that apply Bore hole Solar pump (submersive) Piped Rain harvesting Stream Patients bring their own Other: 15. Who pays for your water supply? Government *Tick all that apply PHU management NGO Community Other:
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16. Is your source of water safe for No drinking? Yes Source for safe drinking water *Tick one Storage tank If no, go to question . If yes, go to question . 17. Do you treat it? No *Tick one Yes *If no, go to question . If yes, go to question . 18. How do you treat your water? Filtration Water purification filters or chemicals *Tick all that apply Chemicals Boiling Other: 19. Do you have a power supply? No Yes *If no, go to question . If yes, go to question . 20. What type of power supply system do Generator you use? Solar Solar panels *Tick all that apply Batteries Other:
21. Who pays for your power supply? Government *Tick all that apply PHU management NGO Community Other:
22. How often do you have power? 0-2 hrs/day *Tick one 2-4 hrs/day
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4-6 hrs/day Note: the higher the number of hours the higher the score 7+ hrs/day B. SANITATION AND HYGIENE 23. Do you have any toilet facilities? No *Tick one Yes Toilet facilities for patients Septic tank *If no, go to question . If yes, go to question . 24. What toilet facilities do you have? Dug pit *Tick all that apply VIP Latrine VIP Latrine Bucket latrine Flush toilet (water closet) Other:
25. How do you dispose of your medical Burning/incinerator waste? Burying Incinerator or Burial pit *Tick all that apply Hazardous waste containers Sharps containers in all treatment areas Buckets for contaminated waste in all treatment areas Other:
26. Do you have hand-washing No procedures for staff? *Tick Yes Hand-washing guidelines posted one 27. Do you have adequate hand-washing No facilities? *Tick one Yes Hand-washing sinks and taps or bowls on stands in all areas 436
28. Do you use gloves? No *Tick one Yes Glove supply 29. What do you use gloves for? Surgical procedures *Tick one Examining of patients *Knowledge levels Laboratory Cleaning C. STAFF MEETINGS 30. Do you hold staff meetings? No *Tick one Yes Staff meeting minutes If no, go to question. If yes, go to question 31. How often do you hold staff Monthly Staff meeting minutes meetings? Quarterly *Tick one Bi-annually Annually When necessary 32. What issues do you discuss at these Information updates meetings? Work plan development *Tick all that apply Challenges Outreach activity planning Financial/Budget Procurement/purchases Staff improvement Emergency issues Other: Staff meeting minutes D. USER FEES 437
33. Do you charge user fees? No *Tick one Yes If no, go to question . If yes, go to question . 34. Which services do you charge user Outpatient fees for? Registration *Tick all that apply Other administrative services Drugs
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