Benequista, Nicholas

Dunn, A.

McGregor, G.

English

IDS OpenDocs

The clinic was surrounded by trees and high weeds. 
One room was locked; researchers later discovered 
that a group of students was lodging there while 
away from home. Judging by the hay and droppings, 
the other room was being used to house one or 
several animals of the grazing variety. None of 
the current occupants of either room were present, 
and there was certainly no sign that health 
workers had ever provided care to local residents 
at the building.
In 1998, the Bangladeshi government resolved to 
enhance community participation in the public health 
system. The clinic described above, visited in 2002, 
was one of the thousands of community-owned and 
managed health clinics created by one programme 
designed to achieve this. The other programme relied 
on non-governmental organisations to set up Health 
Watch Committees. Neither of the programmes is 
considered an example of best practice, but while 
most of the community-owned health clinics were 
quickly abandoned, some of the committees survived.  
At one such Health Watch Committee in the same 
region as the abandoned clinic, researchers found 
members still meeting each month. Each member 
would take a turn at the beginning of the meeting to 
stand up and fastidiously report his or her recent 
activities: how people had been made aware of their 
health rights or how a protest against unofficial user 
fees had taken place. Even in the face of threats and 
intimidation from officials, these ordinary citizens 
were devoting considerable time to carrying on 
this work. 
What explains why one initiative was abandoned 
while the other survived?  
New participatory institutions set up by the state can 
provide opportunities for more inclusive forms of 
representation, bolster community acceptance and 
create real pressure for progressive policy change. 
Research on these particular health institutions in 
Bangladesh, however, found that unless citizens are 
politically aware and mobilised prior to participation
in these government initiatives, these new spaces 
for citizen participation can quickly lose their attraction 
for citizens. The research also found that governments 
have an interest in ensuring that citizens arrive 
informed and mobilised. Without these conditions, 
participatory spaces will fail to provide the legitimacy 
and efficiency that officials hope to obtain. 
Furthermore, if these initiatives for public participation 
are to deliver on their promise of strengthening 
accountability, they must allow for direct engagement 
between citizens, public providers and local and 
state officials.
A common assumption
Behind the ‘people-centred’ Alma-Ata Declaration in 
1978 lies an assumption that community participation 
in decisions about local health services will lead to 
better health outcomes. In 1998, as part of health 
sector reforms, the Bangladesh government attempted 
to enhance community participation in the public 
health system. Two experimental initiatives sought 
to bring about more ‘people-centred’ public
health provisioning. 
In one initiative the Ministry of Health and Family 
Welfare set up community-owned and managed health 
clinics in every village or ward. The community-run 
clinics  were mobilised by the Union Parishad, an 
elected local administrative body. Nine councillors 
would comprise a committee composed of local 
representatives, local service providers, influential 
residents and landless people’s representatives. 
This group would be responsible for the operation 
of the clinic. 
In another initiative, the government set up Health 
Watch Committees, established to allow community 
members to monitor the performance of health service 
providers at the local level. The government enlisted 
non-state agencies such as NGOs working in the 
community to help set them up. Nijera Kori, a rights-
based organisation working in rural areas, was one 
such NGO asked to help set up these committees. 
Nijera Kori proposed two Health Watch Committees
—
In Bangladesh Citizens 
Leave a Legacy in Health
Citizenship DRC Case Study Series
—
Sick of Waiting: Citizen Prescriptions for Better Health Policy03
be set up in the same area and that half the members 
be women. Representatives included people from the 
NGO landless groups, professionals (lawyer, journalist, 
non-government doctor), teachers, and a grassroots 
service holder. However the new health policy 
launched in 2004 disbanded these health committees, 
and only those mobilised by Nijera Kori have endured.
One origin, two paths
Research found that the processes of recruitment to 
the two different initiatives differed significantly. 
Selection for the management of the clinics was 
neither transparent nor participatory. Membership 
was biased towards better-off and professional 
classes. The wives of wealthy men were usually 
selected to fill the spots reserved for women. 
This bias towards the elite limited its legitimacy 
among the rest of the community. Selection to Health 
Watch Committees, in contrast, was fairly transparent 
and more participatory, conducted through popular 
voting at an open workshop attended by a range of 
social classes and affiliates of Nijera Kori. 
The selection process had far-reaching consequences 
for how these organisations have functioned. Social 
inequalities were still present among the members of 
the Health Watch Committees, but efforts have been 
made to overcome them. As one woman said, “I think 
that we always try to participate equally in the meetings, 
but there are differences in educational level and status, 
so there is a difference in people’s ability to think and 
talk. However, if a member is remarkably silent, then 
we encourage them to speak up.”
Another striking difference between the two 
institutions is in their impact on the participants and 
on service delivery. The community health clinics, 
most of which soon disappeared, had little positive 
impact or outcomes, while the Health Watch 
Committees produced a series of interesting 
outcomes. At the community level, people have become 
more aware of what services are available, as 
evidence by rising numbers of people in those areas 
seeking maternal healthcare, immunisation and family 
planning. Awareness of nutrition, hygiene and 
sanitation also improved. As one woman member 
of a Health Watch Committee said, “People are 
now…conscious about healthcare in general. 
When people refer to us in the hospital they get 
better attention. Now they get medicines more often.
And when they don’t get proper healthcare and 
complain to me, then I go to the hospital and speak 
to the doctors.”
What can be improved in the design of 
institutional spaces for participation?
•	 The language and rhetoric of rights and people’s 	
participation among government agents and 		
service providers were used to the advantage 		
of the community to demand accountability, 		
though the lack of a legal framework to regulate 	
the performance of public healthcare 			
professionals allowed government doctors to 		
ignore the community’s demands. 
•	 The decision to establish community clinics did 		
not involve any devolution of decision-making 		
to villagers. Health Watch Committees did not 		
have enough authority to monitor provider 		
performance and with no legal backing, this 		
authority declined even further. 
•	 Resources are needed for people’s effective 		
participation in the form of official recognition 		
and financial resources. The lack of strong and 		
visible official support for community groups 		
undermined the authority and effectiveness of 		
these new spaces. With little financial support, 		
community-run clinics and Health Watch 			
Committees both closed down in great numbers. 
•	 Participation for voice is only the first step in 		
establishing accountability. Even strong voice 		
can be meaningless and fail to influence the 		
performance of service providers if policy 		
makers are not interested or do not have the 		
capacity to listen. 
•	 Alliances of community representatives with 		
administrators and managers are likely to be 		
more successful in establishing accountability 		
because this can ensure the support of higher 		
administrative or powerful members of society.
•	 Community representatives tended to be 	
from elite groups, and the poorer sections 	
of the community were uninformed 	
and unrepresented.
Authors:
—
Simeen Mahmud 
Lead Researcher 
BRAC Development 
Institute 
c/o BRAC University
Aarong House –
19th Floor
66, Mohakhali
Dhaka-1212
Bangladesh
citizenship@
bracuniversity.ac.bd
— 
References:
—
‘Spaces for Participation 
in Health Systems in 
Rural Bangladesh: the 
Experience of 
Stakeholder Community 
Groups’ by Simeen 
Mahmud, in Spaces for 
Change? The Politics of 
Citizen Participation in 
New Democratic Arenas, 
edited by Andrea 
Cornwall and Vera 
Schattan Coelho Zed 
Books: London, 2007.
— 
Editors:
—
Nicholas Benequista 
Alison Dunn 
Graeme McGregor


In Bangladesh Citizens Leave a Legacy in Health

https://opendocs.ids.ac.uk/opendocs/bitstream/20.500.12413/12582/1/benequista_etal_2009_in.pdf

In Bangladesh Citizens Leave a Legacy in Health

Abstract

Similar works

Full text

Available Versions

IDS OpenDocs