Citizens' voice in health policy and programming

Dr. Syed Jahangeer Haider (Population Programmes and Directions, DS, July 24,2004) presents interesting findings about positive correlations between achievements of total fertility rate (TFR), contraceptive prevalence rate (CPR) and allied reproductive health data, and questions the wisdom of emphasis on single focused family planning (FP) approach and over reliance on domicilliary services. Dr. Zakir Hussain (Population Control: Reaching the Remaining Half, DS, August 4, 2004) also argues that further reduction of TFR and increase of CPR will demand a more comprehensive approach to reproductive health, and a greater focus on consumer orientation. Both authors strongly endorse the ICPD approach of comprehensive sexual and reproductive health and both underscore the importance of evidence based debate on various policy/programme options.

The two articles are timely as the government of Bangladesh (GoB), is currently negotiating with the development partners, funding for the current three year (2003-06) Health, Nutrition, Population Sector Programme (HNPSP) and a longer term (2005-10) Strategic Investment Plan (SIP). Various new programme elements, such as demand side financing and diversifying service provision through contracting NGOs, are being discussed and debated between GoB and development partners. Several NGOs, professional organizations and civil society organizations have already been consulted on these new programme ideas. However, it will be useful if there is an open public debate on these ideas through articles published in the newspapers so that citizens are better informed about the implications of these various policy/programme options now under consideration. Many more voices need to join the debate regarding the future directions of our health policy and programming.

Tap here to add The Daily Star as a trusted source

Up to now, citizens' experience of voicing their concerns and interfacing with the government has been far from satisfactory. The two gatekeepers of official policy/programme processes -- government and development partners -- tend to consult "communities and stakeholders" in an ad hoc way. The latter is episodically consulted to give opinions and citizens usually do not get feedback as to how their concerns are being addressed. Additionally, these consultations are rarely sustained. There is no institutional arrangement through which citizens' voice can inform policy and programme design, implementation, monitoring and review, so as to get the desired impact of their "voices." Government and development partners show interest in consulting citizens during the design phase of a policy/programme but appear to lose interest during implementation.

However, empirical evidence from Bangladesh and elsewhere suggests that citizens' voice and oversight is crucial for improving the quality, access and utilization of health services. In Bangladesh, several NGOs and civil society organisations have already started their own community based "health watch groups" to monitor the work of the health services. These have had some success in linking users with providers of health services. But these "voices" are generally trapped at the local level with little impact at the national/central level of decision making. The responsiveness of the system depends on the personality of the local level providers/managers. There is no institutional mechanism through which service users can enhance accountability of the providers to them. Additionally, non-government groups do not have an effective forum of their own at the national level outside of the official processes to advocate the interests of service users and engage with the government and development partners in a sustained way. Moreover, at the national level, organisations of service providers are much stronger consumers associations.

I believe the time has come for academics, civil society groups, and the media to be more proactive in taking an interest in policy debates. This means not simply talking about problems but also about realistic solutions. We need much more open and public debate about the costs and benefits of different policy and programme options. More importantly, we need to discuss more openly which groups would bear the costs and which groups would benefit from different choices the government will make.

A dilemma faced by the academic and civil society organisations is that while they need to maintain independence from government and development partners in setting their agendas, they are also dependent on the same government and development partner sources for funding, who generally provide restricted project funds. Absence of long term institutional and programme funding seriously limits the capacity of academic and civil society organisations to undertake independent research and advocacy. Additionally, for policy and programme relevant research and advocacy, academic, and civil society organisations need access to official documents as well as processes such as meetings convened by government and development partners.

As the government and development partners start to develop a strategic health plan for the future, it will be important to remember that such a plan should contain specific policy and institutional support for effective citizens' voice. Obstacles to participation should be addressed and the capacity of citizens' groups to advocate the interests of users of the health services, particularly of the marginalised groups, should be strengthened.

Rounaq Jahan is a Senior Research Scholar at the School of International and Public Affair, Columbia University, USA.