A health situation in
In this
project a national NGO (Naripokkho) worked together
with a large local NGO (Sankalpa) in one sub-district
in
In looking
at ways and means to hold health authorities accountable, Naripokkho
found that a potential accountability mechanism existed in the Upazila Health Advisory Committee (UHAC) which formally
provided accountability within local level decentralised structures and
processes, but was neglected and therefore defunct.
The UHAC was
intended to improve health and medical services at the hospital, solve problems
at the local level and send recommendations to the appropriate authority. It
was potentially particularly useful as it allowed for civil society
representation and thus could serve as a vehicle through which ordinary
citizens could hold local health authorities and service providers to account.
In addition chairpersons of elected bodies at local and sub-district level were
part of the committee. In the past five years only one meeting of the UHAC had
been held.
The ostensible reason for
not convening was that the chairperson, the local MP, was never present and had
not handed over authority to anybody else in the administration. The real
reason was that nobody expected middle-class professionals like doctors to be
answerable to poor people.
As a first step,
the two civil society organisations forged alliances with key officials, health
providers, elected representatives and local women’s groups whose co-operation
was vital in order to revive the UHAC. They also won the co-operation of the
official responsible for health provision and got his agreement to chair a
meeting to introduce the project to the staff of the local hospital. In
addition, Naripokkho forged alliances with
journalists to encourage the media’s role in changing current attitudes and
prejudices regarding women’s health rights, and drew them into the process of
addressing local health services and holding local institutions to account.
Naripokkho
played a pivotal role in getting the UHAC set up and running. It facilitated a
process of working out the roles and responsibilities of the UHAC, liaised with
the MP, the local health authority, the UNO and other members of the committee
to ensure meetings were held regularly. It encouraged members of the UHAC to be
active in meetings, to monitor health services regularly, to look into ways of
improving the quality of care for women, and to take up cases of violence
against women. Naripokkho was able to bring women’s
voices to processes of setting up the UHAC through raising the awareness of all
participants to women’s needs. Sankalpa, as the NGO
member on the UHAC, played key roles in monitoring service provision in the
hospital on a daily basis, studying the health status of women and gaps in
women’s access to healthcare, and using their findings in the UHAC discussions.
Sankalpa staff thus played an active role in
monitoring compliance to the decisions taken at the UHAC through establishing a
presence at the hospital. In addition, Sankalpa
engaged with the media, who reported on the situation at the hospital on an
ongoing basis.
The two
NGO’s conducted a survey of women patients and members of local women’s groups
to assess women’s health status, their perception about health and rights, the quality of hospital services and attitudes of providers.
Problems highlighted by women in the survey were discussed in workshops with
elected representatives, journalists, women’s groups, health practitioners,
service providers from the hospital, and college students. In all, Naripokkho held fifteen workshops with 335 participants.
The workshops raised awareness on women’s health, gender inequality, violence
against women, male responsibility in sexual and reproductive health, and
rights of health service users. In addition, Naripokkho
raised general awareness on women’s health rights through the publication of
advocacy material.
At the
client level a awareness rising workshop was held with
women community leaders discussing women’s rights to health and the
responsibility of the family and the state in safeguarding these rights. A list
of priority demands were drawn up to serve as the basis on which women workshop
participants could themselves take action in order to increase the
accountability of health providers. One priority was to address the lack of
affordability of health care for poor patients.
Key problems raised by women
participants in all these workshops, and the priorities identified by the
workshop of women community leaders, were brought to the attention of the UHAC.
The serious problem of the complete lack of accountability of the doctors was
highlighted. Doctors attended clinics for only two of the mandated six hours
even while queues of up to 200 patients waited for their services. They charged
fees for supposedly free services at the clinic, and spent their remaining
hours running private medical practices. Other hospital staff
took bribes from patients and were disrespectful.
Naripokkho’s
strategy was to highlight inadequacies in service provision at the same time as
they drew in the service providers as allies and attempted to address their
problems. Problems of lack of facilities affected both patients and service
providers. Doctors were engaged in discussions and were able, for the first
time, to raise problems relating to lack of facilities which made it difficult
for them to provide good quality services to women. At the same time these
discussions served as a means of sensitising them to the needs of poor women.
The MP was mobilised to get
an x-ray machine out of the Ministry of Health, which he did, and to get more
staff, which he managed.
Local
journalists were especially useful in activating the new norms set up by the
UHAC. Their presence at UHAC meetings, their frequent presence at the hospital,
their contact with the patients, their monitoring of corruption and their media
reports of lapses created a public discourse about the need for health
providers to be accountable to users, no matter how poor.
Regular
visits by the municipal representatives acted as a pressure in ensuring that
women received better quality care, and resulted in improved hygiene and
cleanliness. Monitoring by elected representatives had greater impact as it was
based on the power of ‘public mandate’ that elected representatives bring with
them to take decisions on behalf of their constituencies.
Outcomes
Naripokkho
was able to get the defunct UHAC up and running and to galvanise local
officials into taking action to improve the health facilities at the hospital.
The UHAC put in place plans for a welfare fund for the disadvantaged in order
to increase the access of poorer patients to health services.
The daily
presence of the Naripokkho/ Sankalpa
research team, the more regular visits to the hospital by the municipal
representatives and the interest of the media in the process, served as
pressures on hospital staff to perform better. The research team played a
watchdog role monitoring health service delivery at the local hospital and
observing the quality of services. Their presence acted as a pressure on
doctors who began to apologise to them for late arrival and whose care of
patients improved while the researchers were present. The researchers also
engaged with nurses on the need to hold regular health education classes and
nurses responded by providing this.
A significant increase was seen in patient numbers and
a significant improvement in patient care.
Source: Mukhopadhyay, M. & Meer, S.