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Pakistan's health system - understanding the politics and institutionalising a culture of accountability

Palladium’s Empowerment, Voice and Accountability for Better Health and Nutrition (EVA) project aims to empower, organise and facilitate citizens and civil society to hold the governments of Punjab and Khyber Pakhtunkhwa to account for the delivery of quality Reproductive, Maternal, New-born, Child Health and Nutrition services. As part of this broad goal, EVA seeks to create a culture of accountability within Pakistan’s health sector by institutionalising mechanisms that provide opportunities for citizens and the state to monitor and engage duty-bearers at multiple levels of governance. Palladium implements EVA in partnership with the Centre for Communications Programmes Pakistan.

EVA mobilises citizens at multiple levels of governance.

In the third of our EVA case studies we explore the politics of Pakistan’s health system and how to institutionalise a culture of accountability. Click on the DOWNLOAD button for full publication.

In a recent paper on ‘doing accountability differently’, Jonathan Fox and Joy Aceron discuss strategies to address the underlying obstacles to accountable governance. Whilst the literature on social accountability initiatives (see here and here) suggests that they have enjoyed some success at raising citizens’ voice and tackling local issues, evidence for and examples of systemic policy changes to structures that sustain poor service delivery are thin on the ground. Indeed, more often than not, studies suggest social accountability initiatives that raise or engage community level organisations to monitor state institutions and demand better services fail to tackle the down-stream causes of poor governance. They also rarely institutionalise the mechanisms and relationships they build during their lifespan.

Fox and Aceron re-frame this problem as one of scale. They argue that whereas traditional development initiatives have sought to replicate what is thought to work in one area in others as quickly as possible, often at the push of donors, an ongoing focus on establishing and linking-up monitoring and advocacy efforts at multiple levels of a state’s governance architecture should also be a priority. They suggest that ‘vertically integrated accountability initiatives should take scale into account by linking grassroots citizens’ actions with more formal advocacy efforts at the national level, whilst also seeking to broaden their “coverage” horizontally in terms of the geographic and social inclusion of excluded citizens’.

In this sense, accounting for scale involves building the capacity of citizens to monitor all levels of the governance supply chain. This includes establishing the linkages that facilitate citizens’ voice at different levels and giving them the teeth they need to bite when states are unresponsive to calls for change. And, where they exist, improving the capacity of a government’s own watchdog institutions to engage in horizontal accountability. These institutions are necessary (but rarely sufficient) to help mitigate the displacement of corruption from one governance level to another, or from one sector to another. In their paper, Fox and Aceron offer examples of such initiatives in Peru and the Philippines, with the former concentrating on the health sector and the latter the country’s textbook supply system.

Multi-level independent policy monitoring and advocacy. Source: Fox and Halloran, 2016.

Explored in our case study, Palladium’s EVA project displays many of the hallmarks of a vertically integrated accountability initiative. Most notably, it mobilises citizens at multiple levels of governance and links these groups together so that monitoring data and demands can be communicated up the state’s authority chain. At the same time, it seeks to work with emerging provincial level accountability institutions that have been established in the wake of a violent insurgency in the mid-2000s and amidst popular calls for an end to corruption. Through this approach, EVA aims to reverse the trend of donor initiatives that mobilise citizens’ groups at a local level to engage front-line services, only to ignore the structural drivers of poor services and the sustainability of these groups once projects end.

Key to this aim are EVA’s provincial level advocacy and accountability teams in Punjab and Khyber Pakhtunkhwa. They describe their roles as finding and tapping opportunities to strengthen the institutional responses to citizen generated demands facilitated by EVA, which includes connecting the project’s citizens’ groups to senior duty-bearers and accountability institutions. This is achieved through two main mechanisms: Firstly, the Provisional Advocacy Forums (PAFs) that represent the top tier of the project’s social mobilisation efforts; and, secondly, ad-hoc meetings and interactions between programme staff and policymakers that build relationships and coalitions which citizens’ groups affiliated with the project can take advantage of when trying to increase the responsiveness of the government.

Twice a year, EVA’s PAFs bring community representatives, influential civil society members, and programme staff into contact with provincial level bureaucrats, healthcare contractors, and politicians. Their basic function is to provide civic spaces in which issues, which cannot be resolved at the level of the health facility or through the project’s District-level Advocacy Forums’ (DAFs), can be raised and new policy directions discussed. Within PAFs, officials and politicians take part in semi-structured interactions with citizens’ during which problems are voiced and solutions brainstormed. As documented in the case study, these forums have had several successes in eliciting responsive governance.

Yet, EVA is also finding that the PAFs provide platforms on which to build wider coalitions among stakeholders that may rarely meet, those that often work at cross-purposes or, in some cases, have fractious relations. For example, in Punjab Province, the PAF has helped to close communication gaps and power inequalities within the provincial government. This was demonstrated when five Members of the Provincial Assembly (MPAs) from the project’s intervention districts were put on the same platform as the Chief Minister’s Health Advisor. The MPAs took this opportunity to raise the common, yet unsubstantiated, belief that funding for their constituencies’ health facilities is routinely delayed for political reasons. In response, the Advisor declared he would ask the Health Department to work with its relevant district representatives to resolve the issue. It is in this sense that EVA views the PAFs as providing a ‘third model of accountability’, able to exploit opportunities created by Pakistan’s ongoing democratic transition and civil society’s tentative revival.

Secondly, EVA’s provincial team is also working to strengthen the capacity of Khyber Pakhtunkhwa’s Right to Public Services (RTS) Commission and the Independent Monitoring Unit (IMU), both of which are mandated to ensure accountable service delivery. To do this, EVA is feeding its citizen-gathered health facility monitoring data into these institutions, and including their representatives in the project’s various accountability forums. This creates opportunities for them to meet civil society representatives and to hear the stories of everyday hardships behind both their own and EVA’s data. In an unplanned activity, the Commission is also currently drawing upon EVA’s expertise to develop an informational video to educate citizens’ as to their rights and the state’s responsibilities. This collaboration has afforded EVA the opportunity to begin a conversation with policymakers around the definition of what constitutes health ‘emergencies’ in the Commission’s list of 15 essential services that it is mandated to ensure are equitably delivered.

In summary, EVA’s efforts to link up its various forums for citizen-state engagements, and the opportunities it is exploring to institutionalise its relationships with the state’s own institutions appear to closely follow what Fox and Aceron call ‘vertically integrated accountability initiatives’. Nonetheless, it is important to note that EVA’s experience to date (it has several more years to go), suggests that such initiatives need the operational flexibility to seize opportunities to strengthen their own linkages with the state as and when they arise. As will be detailed in a forthcoming research paper, EVA has largely achieved this by ensuring it has a quickly deployable technical assistance budget and carefully negotiating its project goals with DFID. Nonetheless, as others have noted, supporting and enabling such ways of working is likely to require a serious rethink of how development programmes are funded and evaluated.