Citizens' voice and accountability: a political slogan or an institutional mechanism for improving health system in Pakistan

The initiative has great potential but there are important questions

Citizens' voice and accountability: a political slogan or an institutional mechanism for improving health system in Pakistan

By Faraz Khalid (Health Systems Consultant, World Health Organization, Regional Officer for the Eastern Mediterranean), Muhammad Usman Khan (Freelance Health Policy Analyst, Islamabad) and Wajeeha Raza (Health Economist, Agha Khan University, Karachi)

The Prime Minister of Pakistan has recently launched a Pakistan Citizen Portal to address citizens’ complaints in 20 different areas, including health. Several government and non-government interventions have tried to incorporate citizens’ feedback to improve healthcare delivery in the past, but it is unclear whether leanings from these have been incorporated into this portal. The initiative has great potential for including citizens’ voice in improving health system but there are important questions around its enforcement, legal framework and inclusivity.

The Prime Minister of Pakistan recently launched the Pakistan Citizen Portal in an attempt to promote citizen centric governance. The portal is currently available as a mobile application which allows for complaints to be made in 20 different areas including health. The portal is set to be integrated with a toll-free call number and citizens will also have the option of relaying their grievances and concerns to the government through email, letters, and a web portal. It is an integrated platform connecting citizens to all organizations (approximately 4000 government offices) both at the federal and provincial level with each province’s Chief Secretary responsible for ensuring that all the complaints are addressed in a timely manner. However, as impressive as the scope of this portal may be, there are some questions around its potential applicability based on Pakistan’s previous experiences with engaging citizens, particularly in healthcare.

This initiative could be a welcome addition to the health sector in Pakistan, where feedback from citizens is at best slow and at worst does not reach decision making authorities. The current mechanism for feedback in health is through elected representatives, who are responsible for raising health concerns to the minister of health. An additional route for citizens to directly voice their health concerns and provide feedback on the care they receive at government facilities could become a powerful tool for accountability, and could potentially play an important role in Pakistan’s health system governance.

It should be noted that citizen voice and accountability is not a novel notion within the health system in Pakistan. The previous attempts by provincial governments, like Citizen Feedback Monitoring Program (CFMP) in Punjab; complaint cells in provinces, and Citizen Portal in Khyber Pakhtunkhwa included solicited citizen voice on health system functioning. The aforestated attempts included robocalls, text messages, call centers, emails and mobile application as the key methods of bringing forth citizens voice. For example, under the Citizens Feedback Monitoring Program in Punjab, members from a call center would call a sample of patients from secondary care hospitals, and ask questions on whether they received medicines, paid for tests, and if they were satisfied with the cleanliness. The data on medicines was compiled and reported to the secretary, minister and the Chief Minister for a complete feedback loop.

In addition to government interventions like this, donors and non-governmental organizations have also initiated projects which focus on using citizens’ feedback to improve governance in healthcare. For example, two such interventions are Empowerment Voice and Accountability for Better Health and Nutrition (EVA-BHN) by DFID in Punjab and Khyber Pakhtunkhwa and the Citizens Voice by USAID in Sindh. The EVA-BHN project for instance has identified and trained community groups who take feedback from citizens and report either directly to facilities or through district advocacy groups.

Though laudable in their own right, these modes of bringing citizen’s voice in improving governance, both from government and donor organizations, have suffered from limited access, lack of legal framework for their enforcement, lack of legal and institutional frameworks that promote accountability, and limited knowledge on the part of the beneficiaries. In particular, the government mechanisms are also prone to be politicized by either the government or the opposition and in some cases, concerns have been raised over the privacy of data. Any holistic mechanism aimed at promoting citizens voice also has to contend with the idea of citizenship and empowerment. Notwithstanding the hundreds of thousands of refugees in Pakistan who do not have a formal status in the country, even those holding the national ID card are not aware of their rights and lack the basic technical know-how to operate app-based services. This is critical to breaking the current norm of the patron-client relationship between the policy makers/service providers and citizens.

The Citizen Portal, even when it will be expanded beyond the current app to a call center and other digital platforms, is also prone to the aforementioned problems. While there are publically available evaluations for the two of the programs highlighted above, the Citizens Feedback Model in Punjab and the EVA-BHN project by DFID, there is little to suggest that this feedback has been incorporated for health systems governance and service delivery into the Citizen Portal.

Overall, the initiative has the potential to become an important institutional mechanism for much-needed accountability in the health system. However, the lack of a strategy document or roadmap for the citizens’ portal raises important questions regarding accessibility, knowledge dissemination to a technological disenfranchised populace, inclusivity, and legal frameworks of the portal. Perhaps some of this could be answered by gauging previous attempts at engaging citizens to improve governance in health, which leads to our main question on what were the lessons from previous attempts and how have they been incorporated in this portal. While only time will tell the impact of the intervention, without learning from the past it is currently at risk of becoming a political slogan with limited impact.

Disclaimer: Views expressed in this article are those of the authors and do not represent their official positions

This blog post was first published on the Health Systems Governance Collaborative website on 22 November 2018

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