Stories and Stats: The surprising ways citizens demand accountability when it comes to health care

[Editor’s note: In 200 communities in Tanzania and Indonesia, Results for Development and the Harvard Kennedy School’s Ash Center for Democratic Governance and Innovation are working together to see if citizen engagement can lead to fewer deaths among pregnant women and newborns — a tragically common and preventable occurrence in both places. After helping to mobilize the communities, the Transparency for Development (T4D) project team is now looking at the actions the communities have taken to improve maternal and newborn health and why. Using a combination of rigorous quantitative and qualitative evaluation methods, they have found some exciting trends. The “Stories and Stats” blog series provides an early glimpse into these findings. This is the second post in the series. In the first post, “Stories and Stats: How qualitative methods help us read between the numbers,” Hannah Hilligoss looked at what it actually means to “advocate for reform,” — and how the stories behind the numbers can be revealing.]

Engaging citizens — particularly around an issue like improved health care — is a tricky endeavor. Accountability is a key piece of the equation, but the term conjures up a lot of preconceived notions, many of which are negative and could lead government officials to quash efforts before they even begin.

In this post, we take a closer look at how the citizens of 100 villages in Indonesia are holding their officials and health care providers accountable for improved health outcomes. These trends reveal important information that can help us confirm or breakdown our assumptions about how communities undertake and approach accountability work.

Collaborative over contestational

If you talk about “accountability” with a government official, the term is likely to conjure images of angry protestors in the street, seeking to burn officials at the proverbial stake.

However, our early review of social actions in Indonesia reveals something very interesting about this type of accountability work — in the majority of cases, the actions that communities are taking to improve governance and health are actually collaborative, not contestational. In fact, only 6 percent of the total actions designed by community activists could be classified as being contestational.

And what does this “contestational” approach look like in reality? Most of these actions involve sending complaint letters, not massive protest (an action that we have not seen in any community). And, in many cases, these were actions that sought to give voice to those who had negative experiences with their health services and did not otherwise have a path for having their voices heard.

In one village, community representatives built a complaint box outside of the health facility for patients to anonymously report when they had negative experiences at the facility. In another village, the community representatives filed a complaint letter to the subdistrict facility head on behalf of a woman who had not received proper referrals from the midwife for the hospital.

Another trend that reviewing these actions reveals is that many communities only turned to contestational actions after first (or second or third) attempts to solve a problem in a collaborative way did not work. In one case, community representatives sought to work with the village head to fix the road to the facility, which they said was in such poor shape that women could not get to the facility to get proper care when they are pregnant. After two separate attempts to meet with the village head to discuss this issue with him, they finally scheduled a hearing during which they confronted the village head about the poor quality of the road. In order to be heard, the community representatives had to resort to a slightly more confrontational approach.

Short vs. long route of accountability

The transparency and accountability field has long referred to the two routes of accountability — the short route (in which citizens seek to directly change the behavior of service providers) and the long route (in which citizens request that their government officials step in to hold service providers to account). However, how these long-route actions work in practice and how they develop organically is not as well studied.

In Indonesia, we found that long-route actions, which we define as actions targeting government officials above the village level, are relatively common, with 35 percent of communities designing at least one action that targets higher-level officials. And the stories behind these actions reveal that, like contestational actions, these long-route actions often happen after other actions have been tried without the intended results.

One village that wanted to improve the availability of medical supplies and an ambulance reveals one interesting pattern. In the initial social action discussion, the community representatives decided to start by working with the village head to improve supplies and transportation. After 30 days, these representatives revealed that they had a productive meeting with the village head but decided to move up the chain to the sub-district head to make requests for the ambulance, which the village head could not address. In a subsequent follow-up meeting, community representatives reported back that the sub-district head would make an ambulance available but did not have the funds to pay a driver, which resulted in the community deciding to take this up a step further to their legislator. This is an ongoing effort, so the full story has not yet emerged — but this evolution of actions reveals important lessons about how “long-route approaches” may develop.

Why these stories and stats matter

Knowing that implementing an accountability-focused community health campaign is unlikely to lead to confrontational interactions between government and their constituents may help donors and practitioners alike to be less gun-shy about incorporating social accountability practices into their health programs.

And the stories can help practitioners and donors understand that actions like those targeting higher level government officials often don’t just happen — they evolve based on the experience and observations of community members regarding what works and what doesn’t. This may mean that regular follow-up and facilitated opportunities for communities to iterate are key to getting from the short route to the long route.

This is just the tip of the iceberg, and in the coming months, we’ll be sharing more — by the numbers and what those numbers mean. In the meantime, if you’re interested in learning more about the T4D approach to mixed methods, check out our podcast from the Stories and Statistics event!

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