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“Free Healthcare, Free Die” the Efficacy of Social Accountability Interventions in the Health Sector in Sierra Leone

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“Free Healthcare, Free Die” the Efficacy of Social Accountability Interventions in the Health Sector in Sierra Leone “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 ii 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. iii 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 iv 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 .........................................................................................................................
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