This summer, I made a project visit to a government clinic in northern Sierra Leone. It is a clinic pretty much in name only, being constructed as 1-bedroom living quarters for a teacher and subsequently converted into a health facility. The nurse took me on a tour, pointing out the problems: a broken scale to weigh infants, no waiting room for early stages of labor, animals grazing and
leaving waste by the clinic entrance, missing IV materials and drugs, to name just a few. She then turned to me, visibly frustrated, and asked what I would recommend. I asked her if she had tried complaining. “You want me to report my boss to human rights?!” she responded, incredulously. Her assistants at the clinic broke out in laughter. How could she possibly complain up the chain of command?
When I first started working on accountability projects in Sierra Leone in 2011, I jokingly told colleagues that my goal was to contribute to a culture of complaining in the country. My words were in jest, but the spirit behind them was not. Witnessing a range of systemic breakdowns in health delivery, at all levels, I sensed a deep need for citizens and service providers to formulate and direct their grievances. I started to view grievances as a type of public good—a service provided for the benefit and well-being of all members of a community.
There are a range of reasons for this. A single grievance can, if acted upon, lead to dramatic change—IV supplies may save the life of a woman in labor. Grievances also show the government that citizens expect it to deliver services. This has not always been the case in Sierra Leone where citizen-state relations have suffered historic breakdowns, and where NGOs have often filled gaps. And when aggregated, grievances can help government set priorities and revise and improve policy.
As the Justice for the Poor program has worked with the government to design and implement interventions to improve accountability for health services, we have charted our progress, in part, by measuring the number of complaints filed, as well as the ways in which they are resolved (or not). I have seen firsthand the barriers to people complaining. Entitlements aren’t clear so people don’t even know what they can rightfully complain about. Individuals like the nurse fear that government won’t respond or, even worse, will retaliate by denying promotions or transfers to more accessible urban locations. And certain grievances are too complex for individuals or communities to tackle on their own—they need agents to represent their interests.
If grievances are a public good, then what might be some ways to remove these obstacles?
- Clarify and broadcast individuals’ rights and/or duties. Donors frequently emphasize that individuals must know their rights before they demand them. Yet, we often under-invest in helping government develop and disseminate coherent, practical, and clear policy. As just one example, our Justice for the Poor team has spent the past year working closely with government to clearly articulate rights under the President’s Free Health Care Initiative and how those rights fit into the broader health policy landscape. These are not simple issues to resolve, but if the landscape is unclear to government, we should not expect it to make sense to citizens, nurses, or their agents.
- Strengthen existing complaints channels. Donors often focus on project-specific grievance redress mechanisms (GRMs). Indeed, a World Bank social accountability human development portfolio review completed last year identified GRMs in 23% of Bank-funded projects containing social accountability elements, but these GRMs had a predominantly inward focus—on making sure the project works well. Can we move towards strengthening existing accountability mechanisms (such as administrative complaints offices or ombuds persons) that will live long after a project (and its GRM) has closed?
- Consider structured processes, like community compacts, that can frame complaints as collective community concerns to mitigate fears of individual retaliation and facilitate communities and service providers acting together to prompt change.
- Use agents of the complainant (paralegals, chiefs, community accountability committees, or otherwise) who have enhanced information, skills, or authority, and yet some independence from the service deliverer, to take up complaints involving large power imbalances or broader structural breakdowns.
As we’ve tested these theories in Sierra Leone, we have seen evidence of other, relational ways in which grievances can serve as a public good. Community members have reported that they are happier with the quality of services after complaining. Nurses and community members have forged stronger bonds and have starting working together, even when their complaints have been initially directed at one another.
I discussed this possibility with the nurse—how her complaint might actually be a good for the community. We triaged her concerns and brainstormed ways in which she could work with the community to resolve issues like animals grazing near the clinic, as well as ways in which she might safely complain up the chain of command and engage others to act as her agent in so doing. She seemed cynical, but less so—the laughter, for one, had ceased. She committed to taking a first step as a complainant: she noted there was a powerful town chief dedicated to development; she would visit him the next day and voice her concerns.