Social Accountability vs. Government Monitoring: The Search for Effective Strategies to Reduce Corruption in Maternal Health Service Provision. The experience of My Health, My Voice in Uttar Pradesh, India
Citizens of many countries low and middle income are routinely asked to make informal payments for health services.
Both government and civil society-led monitoring have been used to reduce the prevalence of informal payments. There are pluses and minuses to each approach.
In judging the relative benefits and drawbacks of civil society versus government-led monitoring, there are several issues to consider. Some include:
- – the potential risks and protections for those who report corruption,
- – whether or not the government – or at least some actors within it – are committed to ending corruption, and,
- – whether and how the monitoring system is embedded in a larger system or effort to ensure an individual or a collective remedy.
Our experience addressing the high prevalence of demands for informal payments for maternal health services in the state of Uttar Pradesh (UP), India, demonstrates some of these risks and benefits.
From 2014 to 2016, SAHAYOG, a women’s health and rights organization, ran an anonymous telephone reporting hotline called Mera Swasthya Meri Aawaz (MSMA)—or My Health, My Voice. While government policy provides that maternal health care is entirely free in UP, health providers often ask women to make informal payments for care, for medicine, and for other services. SAHAYOG and local women’s groups undertook extensive campaigns to ensure that women knew about their rights to free maternal health care, and to inform them about the hotline. The hotline used an open source technology that mapped reported demands for payments in real time and displayed these on the project website.
After the MSMA hotline had been operational for about 18 months, the government of UP acknowledged that informal payments could be a burden for poor families, and that they might discourage women from seeking maternal health care in a health facility. In response, they modified SAHAYOG’s approach and created a state-wide, government-run, hotline.
There are several key differences between the government-run hotline and SAHAYOG’s hotline. First, unlike MSMA, the government hotline is not anonymous; complainants must report their own names and that of the health provider who requested the payment. This may pose a risk to women reporting, as they fear retaliation from the health provider. In rural areas, women may be entirely dependent on the local provider, as they would have to travel quite far to reach a different facility.
Moreover, the government-run helpline has not been well-publicized and the data are not publically available. In fact, SAHAYOG had to file a formal Right to Information request to obtain information about the number of cases reported to the government hotline. SAHAYOG learned that in one year of operation (2014) the government line received approximately 300 calls from 75 districts of UP. In contrast, the MSMA line received approximately 1,300 calls from just 4 districts during the same period.
The government has not released any information about action taken in response to the complaints they received. In contrast, rather than following up on individual complaints, SAHAYOG used the data collected via their hotline to hold one on one meetings and community meetings to advocate for stronger protections against informal payments at the facility, district, and state levels. They argued that the data showed a systemic problem that required a systemic solution. They felt it would be unfair to solely penalize frontline providers who often lack the basic salary, equipment, and support to do their job, and who operate in a system that is permeated by corruption at all levels.
Yet, some women who called the MSMA hotline wanted direct action in response to their specific complaint. While we do not know if the government of UP punished individual providers or offered individual remedies to complainants, in theory, the state-run hotline is set up to pursue individual instances of demands for fees.
Government-run monitoring systems can conceivably reduce frontline corruption, as the monitors are able to take immediate action to sanction misconduct. However, this will work only in the context of significant commitment and capacity to reducing corruption, and to protecting reporters from retaliation. Moreover, in order to encourage reporting, such efforts require significant campaigning and awareness raising to teach women about their entitlements and about the monitoring system. Finally, data collected through monitoring should be freely available so that citizens can monitor changes and the media can play their watchdog role. Without these pre-conditions, government monitoring efforts can serve as a fig leaf for inaction. In this context, donors and other policy-makers should be cautious about pushing for governmental assumption of responsibility as the only route to sustainability.
About the Authors
Zoe Stopak-Behr, MIA, MPH. formerly worked as a Graduate Research Assistant for Averting Maternal Death and Disability (AMDD). She now acts as Project Management Director for Bronx Partners for Healthy Communities, a network of medical and social service providers seeking to transform the Medicaid care delivery system in Bronx, NY.
Marta Schaaf, MIA, MPH is the Deputy Director of the Averting Maternal Death and Disability Program at the Columbia University Mailman School of Public Health. In this role, she develops program research and implementation to promote accountability for maternal and other health programs. Marta has worked in health and human rights for nearly 15 years. She is currently pursuing a doctorate in public health at Columbia University.
Dr. Y.K.Sandhya is the Assistant Coordinator of SAHAYOG, an organization that works on youth and women’s sexual reproductive health and rights in the northern state of Uttar Pradesh in India. Dr. Sandhya has been trained in social medicine and community health from Jawaharlal Nehru University. She has experience of working on sexual reproductive health and rights and plays a significant role in advocating with Officials of the Ministry of Health and Family Welfare, the Secretariat of the Parliamentary Standing Committee of Health and Family Welfare and the National Human Rights Commission.
Pravesh Verma is currently he is working as Sr. Programme Associate and is the ICT officer at SAHAYOG. He is a specialist in gender equality, violence against women, and sexual reproductive health and rights. He is pursuing his doctoral degree from Mahatma Gandhi Kashi Vidhyapeeth.