Accountability in Health Services

Neil Anderson, 9th IACC, Workshop contribution, Private Sector

Accountability in Health Services
Bangladesh, Nicaragua, Pakistan, South Africa, Uganda

Neil Anderson, CIET


"Citizens denounce corruption," read the front page headline on Nicaragua's national daily La Prensa after CIET social audit results of public sector integrity were released in September 1998. Health centres were identified as corrupt by 40% of the population

'Social audits' of health services were carried out in Bangladesh, Nicaragua, Pakistan, South Africa and Uganda.

CIET social audits gather data from households, communities and local public service workers about how well the public services serve the public. They focus on system flaws and create locally identified solutions for regional and national reform.

Done at the request of the National Integrity Commission of the Nicaraguan Government, a social audit found large regional differences in the price people had to pay for primary health care. Only around 20% of users ever got a receipt.

Irregularities in the costs of care were also detected in Bangladesh, in a social audit commissioned by the government of that country. More than a fifth of those who visited government health facilities made an extra payment to the health worker, and nearly a third paid an unofficial registration fee.

Extra payments for supposedly free services are a disincentive for many who should use government health care. Of those who did use the services, 13% said there was no health worker there when they arrived to the facility.

When public servants are late for work or absent, their salaries and the time people spend waiting for them is lost. This is part of the 'system leakage', the wastage of public resources. By documenting where these leakages occur, local solutions can help to reduce the waste, establishing a baseline to measure improvements over time.

In the Wild Coast, South Africa, immunisation is supposed to be a free service. Yet it is a big personal earner' for government health workers. Compared with lower impact treatments, such as those for diabetes, heart problems and diarrhoea, the cost of vaccination was more than double. Childbirth was another service that brings health workers unofficial "extra fees'.

Another example comes from Pakistan where nearly all of the 23,000 women interviewed said they had paid for delivery even though government hospitals and primary health care centres claimed the service was given free of charge.

Medicines that disappear from, or never reach, the health clinic was another common form of system leakage reported through social audits.

The evidence base:
Bangladesh: 134 926 people
Nicaragua: 6 000 people
South Africa: 14 353 people
Pakistan: 170 000 people
Uganda: 1995: 27 196 people
  1998: 94 481 people
  1 595 service workers

"My son was vaccinated with water because we were too poor to pay the health worker extra"

As a follow-up to the 1995 baseline on performance and perceptions of health services in Uganda, the 1998 National Integrity Survey was conducted by CIET at the request of the Ugandan Inspector-General. It found citizens were less likely to pay "extra fees" if they knew the facts about how the public service works and what to expect.

The social audit mapped out what information people needed. As a result, every district in Uganda now has follow-up workshops to discuss a plan of action.

Asked what communities could do to counter corruption themselves, many community members said they could refuse to pay bribes. "There is no receiver if there is no giver," one man said in a focus group discussion. Extensive media coverage of audit results helped to reinforce this message.

Each social audit finishes with one of these "workshopping" processes, where evidence is shared solutions developed with them. Follow-up surveys measure the impact of these reforms.

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