Social Accountability is getting more and more innovative these days. A recent event organized by Justice for the Poor (J4P) showcased a pilot program in Sierra Leone where a group of development practitioners are exploring new ideas on social accountability and how legal empowerment tools, such as community paralegals can play a complementary role by helping communities navigate the murky waters of administrative accountability and hold the government and the healthcare service providers accountable.
Funded by the Nordic Trust Fund, this pilot program complements Sierra Leone’s Free Health Care Initiative (FHCI), a national program which was announced in April 2010 and promised to provide free healthcare for children under 5, pregnant women and nursing mothers. (See related article here) The initiative however continues to face operational and governance challenges such as absent nurses, charging fees for what is supposed to be a free service, and disappearance of up to 30% of drugs before reaching clinics according to civil society organizations, all of which the program is trying to mitigate. (See related blog here)
Some of the most interesting features of the pilot program include using a ‘two-way contract’ where both stakeholders, communities and nurses, are accountable for their share of responsibilities and rate each other on their performance. For example, “the nurse agrees to increase outreach, while community agrees to build hammocks to carry patients to clinic”, said the presenter, Margaux Hall. Under the two-way contract, each stakeholder has responsibilities in order to achieve a common goal. This creates a common purpose, emphasizes teamwork and provides a sense of ownership in ensuring that services are delivered properly. The contract also evolves along with community needs, providing flexibility to the process and spirit of learning-by-doing.
The use of community paralegals is also a unique way to help the community get services to which they are entitled under the new national initiative. According to the presenter, these paralegals are already present in 36% of Sierra Leone’s chiefdoms, helping them access basic justice services. Yet, they have not traditionally deeply engaged with issues around healthcare service delivery. The program partners with a local paralegal organization called Namati that has trained paralegals in promoting accountability in healthcare delivery.
While the impact of the program is still being evaluated, the presenters identified some preliminary lessons learned: “Invest time in understanding local context and capacity before designing social accountability mechanisms; citizens and service providers need to know their rights before they can demand them; and important to establish a partnership given dependency on local service providers and risk of retaliation” - all of which are critical in effective social accountability programs.
During the presentation, the presenter and some participants raised the question of sustainability due to expensive, donor-reliant nature of such programs. Scorecards used to rate the performance under the contract tend to be expensive. Similar concerns have been raised about the sustainability of the free health care initiative itself by Vijay Pillai, Country Manager to Sierra Leone in his blog, “first year public spending for the initiative has been about 2.8% - roughly doubling the share before FHCI”, and much of it has been through donor and government funding (see here). The survival of FHCI itself is at risk if there is no continued political commitment for adequate fund allocation, said Pillai. In addition, Namati also relies heavily on external funding from international agencies.
One can only hope that this fascinating initiative is sustained so that when it is properly evaluated in future, we can all learn important lessons.
Photo by southernfried.