The issue

1The action research project has addressed the issue of developing effective accountability of the State as a critical aspect of the assertion of the citizens’ rights. It has done so by (a) Examining how medical care is given in an Upazila Health Complex (UHC) focusing in particular on treatment of women; and (b) Initiating citizen actions and reactivating steady accountability mechanisms.

2To achieve this aim, the project tested out some strategies at the local administrative (Upazila) level in order to assess their efficiency and their effectiveness. The project was settled in the Pathorghata Municipality, and involved health care providers, mainly from the local hospital. The objective was to make them accountable to their women patients. This project also informed some women’s groups and patients about their rights to demand and receive proper health support services from government agencies.

3Compared to developed countries the maternal mortality rate is 100 to 500 times higher1 in developing countries. Most mothers suffer from different diseases related to maternal health, after delivery. It was found in the last International Conference on Population and Development (ICPD) follow up project, implemented by Naripokkho, that a woman suffers simultaneously from an average of 5 to 6 different ailments. The main reasons for this high morbidity were identified: women lack consciousness about their own health needs; they lack knowledge about reproductive health rights and information about the availability of health services for them; women’s health needs are neglected by family members; conservative societal practices prevent women from attending health clinics or hospitals; and finally economic constraints reduce the part of family resources spent on women’s treatments2.

4Three Bangladeshi women die every hour from complications related to pregnancy and childbirth. The current estimated maternal mortality rate (maternal deaths per 1000 live birth) of 4.5 is not only among the highest in the world. It is also unacceptably high in comparison to countries such as Sri Lanka (.8 per 1000 live births). Globally, maternal mortality rate of a country is now considered as an indicator of the overall status of women. In Bangladesh, MMR represents the end point in a life time experience of gender discrimination, neglect and deprivation. But it also reveals the incapacity of the health system to effectively provide services and care for the people. In the last decade of the twentieth century maternal mortality is no longer a challenge to medical science. No new discoveries are needed to save women from death due to pregnancy related causes; the answer lies in the social and political spheres.

5Yet, the high rate of maternal mortality continues to be a challenge for Bangladesh. With about four million pregnant women every year, an estimated six hundred thousand (600.000) women develop complications. Many of these women succumb, their lives ending in pools of blood, in the throes of convulsions or even in the agony of their bodies being torn apart.

6About nine million women have survived the rigors of pregnancy and childbirth to suffer from lasting complications such as fistula, prolapsed uterus, inability to control urination and painful intercourse. The disadvantaged situation of girls and women and their adverse social and economic status contribute to the many health and nutritional problems they face3. An epidemiological assessment of causes of death among women aged 10 to 50 in Bangladesh was conducted by the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERHT) across the nation. Its findings are presented in the table below. As the table shows, the highest percentage (46.6%) of deaths is due to non-maternal medical causes. Even deaths from injury and poisoning are more frequent (21.5%) than maternal mortality (20.1%).

7The Bangladesh Bureau of Statistics (BBS) indicates that deaths due to unnatural causes among women are higher than deaths due to maternal complications. Moreover, demographic surveillance data from the International Centre for Diarrhoeal Disease Research of Bangladesh (ICDDRB) indicate that nearly 14% of maternal deaths are associated with an injury caused by violence.

8One critique of the government’s health programme is that services to women tend to concentrate on maternal and reproductive health. But women’s health encompasses much more than maternal and reproductive health. No specific services are designed for women who are not sexually active, for those who do not have problems related to reproductive health, or for post-menopausal women in the current health programme of the Bangladesh Government. Findings from Naripokkho’s other projects such as “Pilot Study on Violence Against Women” and “Monitoring State Interventions to Combat Violence Against Women” also underline the urgent need to shift the focus of health programmes to women’s health as a whole.

9Ironically, in spite of the apparent policy focus on reproductive health, the design and quality of services run counter to the real interest of women. As an example, the priority given to reaching high rates of contraceptive prevalence leaves no scope for addressing the potential side effects of contraceptive usage. 82% of total births are still unassisted by any trained health service provider (Situation of Women in Bangladesh, Policy Leadership and Advocacy for Gender Equality (PLAGE), in Ministry of Women and Children Affairs, Government of Peoples Republic of Bangladesh, March 8, 1999). This shows that even for maternal and reproductive health the situation prevailing in Bangladesh is abysmal.

The importance of the issue for Naripokkho’s overall goals

10Naripokkho has earned a reputation as an advocacy group for women’s health and rights within the Ministry of Health and Family Welfare. Naripokkho’s activism in favour of women’s health is rooted in the very experience of women. This linkage to the grassroots and the ability to analyse the grassroots experience at national policy and program level has given Naripokkho the opportunity to sit at the table of the government of Bangladesh.

11With the objectives, through the ICPD Follow-up project, of “Ensuring Accountability” and enabling local people, particularly women, to hold health services providers and the State accountable for providing appropriate and sensible services to women, Naripokkho has built a reliable partnership with Sankalpa in Pathorghata where the Gender, Citizenship and Governance (GCG) action research project was based.

12The current project provided Naripokkho with the opportunity to strengthen and widen the model they had started working on in Pathorghata. Naripokkho was able to maintain and develop their relations with the health sector at national level, which enabled them to make sure that the lessons learned in Pathorghata have the biggest possible national impact. This required Naripokkho to be active and visible and continue to be involved in various government committees on health issues.

Introduction of research project

Project goal

13To improve health services for women at local level in Bangladesh through the reactivation of government instituted accountability mechanisms for health service providers.

Objectives

1. To make the local health authorities and service providers accountable to people, particularly to women.

2. To make the health authorities and service providers more gender sensitive.

Strategies

1. Give technical support to the members of the Upazila Health Improvement Committee, local leaders and government health services managers. Enable them to objectively assess the situation and resources of health services and to implement adequate measures.

2. Facilitate monitoring and data collection by the local NGO and compilation, analysis, preparation and diffusion of reports on women’s health problems.

3. Build the capacity of patients, that is local women’s groups and women patients, to hold health services providers accountable.

4. Maintain a link with the Ministry of Health and Family Welfare, the Department of Health Services and the Department of Family Planning.

Research question

14To what extent do these strategies create accountability at local level and what strategies lead to sustainability and transferability of this effort?

Type of activities undertaken

1. Consciousness-raising through training and workshops

2. Identification of the barriers existing between health services providers and patients inhibiting accountability

3. Technical Support to the local NGO and the Upazilla health advisory committee (UHAC)

4. Renewal of advocacy linkages with health authorities at national level

5. Documentation and diffusion

Institutional actors involved

• Local NGO, Sankalpa

• Elected member of Parliament (Patharghata MP)

• Elected members of Pouroshava (Municipality Corporation)

• Elected members of Local Administration (Union Parishad)

• Local journalists

• Women’s groups (consumers)

• Patients at the hospital (consumers)

• Members of the Upazila Health Advisory Committee

• Health services providers (Doctors, nurses, paramedics, health educators, family welfare visitors, family welfare assistant, family planning inspectors, health assistants, assistant health inspectors, health inspectors, technicians, medical assistants, Aya/Peon)

• Other health practitioners.

Institutional Framework of the Project Activity

Main assumption

15The assumption underlying the designed strategies and activities is that accountability of health services providers to people and particularly to women can be ensured by re-activating existing administrative structures already in charge of monitoring the quality and effectiveness of local health services, such as the Upazilla Health Advisory Committee. This assumption could turn out to be true under specific conditions: the chosen monitoring unit must become a really participative structure involving State and civil society representatives, such as elected representatives, civil servants, members of local women’s groups, journalists. In addition, everyone has to be aware of their rights and responsibilities and work collectively on the quality of health services provided to the people of the area, especially to women. Then in spite of the resource constraints and imperfections in the health infrastructure women’s health status will improve. Moreover, the problems that will remain unsolved could then be identified, and recommendations could be made by the UHAC to appropriate authorities – which have the necessary mandate to do so and whose members have access to the highest law making body, the Jatiyo Sangshad (Parliament).

16It is also assumed that Naripokkho as an external agency, along with the local partner Sankalpa, would play an enabling role as facilitator and would make the necessary institutional linkages to reactivate the process.

17The third assumption is the following. If the strategies applied happened to be successful in the selected locality then the model could be advocated for replication in other parts of the country.

The Health Infrastructure in Pathorghata

Analysis of the achievements

18The following analysis has been made on the basis of the research questions “To what extent do these strategies create accountability at local level and what strategies lead to sustainability and transferability of the UHAC?”

Activities to initiate the action research

19In collaboration with Sankalpa, Naripokkho focused its activities on two main spheres: the Pathorghata Upazilla Shasthya Prakalpo (the local hospital) and the UPAC. Women using the hospital services were also involved as well as local journalists who acted as a lobbying group. In addition, activities were organised by Sankalpa for the information of the members of local women’s groups – many of whom are regular users at the hospital – and also of the elected members of the UPs and the Pouroshabha in Pathorghata. The objective was to mobilise public opinion and urge them to claim accountability from the health services providers.

20Naripokkho carried out the following activities:

• Consciousness-raising on the issue

• Workshops to build capacity and raise awareness among health services providers, users, journalists, etc.

• Survey to assess women’s health needs and the quality of health services provided to women

• Monitoring health services provided by the local hospital

• Local advocacy and lobbying to activate the UHAC

• Technical Support to the UHAC

• Alliance with local media to publicise the issue

• Advocacy with relevant Ministries at national level

• Documentation and dissemination

Initial outcome of the project

21– During the last 10 months 6 UHAC meetings have been held. The UHAC has been active in bringing about a change in the quality of health care. They have tried to solve problems at local level when it was possible, and otherwise have put forward concrete recommendations. On November 28th 2002 an UHAC meeting was called on the initiative of its members without Naripokkho acting as a catalyst. Almost all members were present and the meeting was carried out very successfully. The MP and the UNO have played a major role in making the UHAC effective, which is a very promising indication for healthcare in Bangladesh.

• To its constituents’ satisfaction, the MP has funded the repair of the health complex facilities. In a short span of time he was able to arrange for an X-ray machine to be given to the hospital, for rural electification to be implemented and for a new doctor and health workers to be recruited.

• The UNO funded the accommodation for the doctors. He also maintained a link with the doctors and hospital authorities to ensure proper health care.

• Pouroshova members regularly visit the hospital to ensure that women are receiving quality care. The Pouroshova commissioner put up a sign stating ‘Do not give money to anyone without a receipt’. He also took on himself to get a sweeper to clean the place.

• The authorities have also tried to help the poor and destitute by coordinating their efforts. They have requested the UHAC to create a Welfare fund for the disadvantaged.

• The state of hygiene and cleanliness of the hospital is now satisfactory.

• In the last 4 months patients have been coming to the health complex in greater numbers (200/300) and all are receiving proper and properly organised treatment after getting a ticket.

• Many people, especially women’s groups, are working hard to improve health care services to women – and more and more people feel encouraged to participate in this effort – Local journalists are raising the issue of women’s health in the local papers and writing about the problems faced by the health complex.

• Naripokkho and the local NGOs helped create and maintain communication, cooperation and links between medical care providers and receivers.

• The local NGO has played an important role in ensuring women’s participation in health care by regularly monitoring the hospital, collecting data, exchanging views regarding health in the local community and helping to solve arising problems through dialogue. They also played an important role in UHAC meetings’ organisation.

• The presence of Naripokkho in various health committees enabled the issues and problems raised at local level to be brought to the attention of the decision-makers at national level.

• Naripokkho also had the opportunity to increase the awareness of these problems in the national and international level meetings of the “PHC”.

Recommendations

22The referral system has to be improved. There is a need for coordination between care providers and receivers on this topic.

• The following emerged as issues which needed to be tackled at National Level:

1. 1. Ensure the position of doctors nurses at the health complex.

   2. Carry out pathological tests at the health complex

   3. Training of TBAs

   4. Improve EOC facilities at the thana level

   5. Stop target-oriented family planning programmes

   6. Regularise UHAC meetings

Limits of the project

23Eighteen months is a very short time to make care providers accountable for ensuring proper health care. Only a fraction of this enormous problem could be tackled in this time. More time, continuous research, monitoring, identification of local role models, awareness and involvement of the community and work at national level are all needed to address this issue.

Final remarks

24Through this Action Research Project Naripokkho has been able to prove that a conscious step can make a difference. The UHAC has become more sensitive to the issue of accountability to the people of the Pathorghata Upazila health complex. One of the committee members put up a sign board at the front of the hospital saying: “Nobody should pay any money for the services being offered by the doctors at the hospital premises, and if for any reason any money is paid make sure to get a receipt from the concerned authority”. Due to the regular presence of project staff, doctors are now attending the hospital in time and the cleanliness of the hospital has also improved.

25The Upazila Nirbahi Officer raised the necessary funds to repair the toilet in the hospital premises. The Upazila Family Planning Officer himself voluntarily took the responsibility of supervising the work to minimize the costs. The Chairperson of UHAC who is a Member of Parliament has obtained an X-ray machine for the hospital. The Committee also took the initiative to create a ‘Poor Patients Welfare Fund’ where a percentage will be earmarked for women patients only.

26Thanks to this action research project Naripokkho has been able to identify a key mechanism that can make health services institutions become more responsive to users’ needs – it is throwing a bridge between services providers and users, the bridge being in this case the UHAC. Although the UHAC is a formally constituted body, it had never been convened in Pathorghata, like in most other parts of Bangladesh. Through the project activities in fact, Naripokkho firstly worked out in practice what the role and responsibility of UHAC ought to be and also managed to get the UHAC going. Since the formal constitution of the UHAC Naripokkho attended only one of its meetings in five years. During the last phase of the action research project, not less than five consecutive meetings were not only convened but also effectively held with the active participation of all stakeholders.

27The research showed that the first step towards the set up of a system of accountability of governance institutions is to create a culture and a demand for accountability. Through its various meetings and work-shops with different categories of health services users, particularly women, Naripokkho created an environment in which users could come and expect sensible and appropriate answers from the services providers. Naripokkho’s research team also played the role of a watch-dog body, persuading the services providers, particularly the doctors and the nurses of the local hospital, to if not change their ways with the patients completely, at least acknowledge their under-performance and failures. They achieved this result most of the time by providing them with a space where their own problems could be aired and addressed. In cases of negligence of patients Naripokkho used their alliance with the local media to make a public issue of such events, which prompted remedial action by the hospital authorities. In short, Naripokkho demonstrated that a culture of accountability could be built, even in the most apathetic and negligent institutions, if users become conscious of their entitlement to proper services, and can seek redress or influence services providers through a representative body.

28Naripokkho’s research also showed that formal bodies that are set up to play such a role, namely the UHAC in this context, can be activated if all stakeholders can be motivated to participate in its functioning process. Naripokkho’s role was that of a catalyst, creating a sense of urgency for the issue to be taken up and the UHAC to be activated. It also made it easier to kick start the UHAC by providing it with a blue print of the supervisory role it can effectively play and the strategies it can follow. Then could be added its own strategies and activities that had proven impact on initiating behaviour change among health services providers. By working in collaboration with a local NGO, the action research project has also laid grounds for the endeavour to be sustainable, with the possibility that Sankalpa will continue to play the facilitating role in maintaining the demand for accountability among the users.

29To draw general conclusions from this action research project, building formal supervisory structures cannot alone ensure accountability of governance institutions. What is required in making institutions accountable to the public they are supposed to serve is both a culture of and a demand for accountable services and an active partnership between State and civil society stakeholders. To secure accountability in the governance of service providing institutions, such as the health services institutions, users and services providers have to participate equally in its management.