Service Delivery Protests and Community Monitoring

I believe there is great potential for more community involvement to assure quality provision of public service in South Africa. Just look at the increasing number of public service protests all over the country. People are angry and are prepared to act. However, burning cars and throwing bricks might get government’s attention, but won’t increase nurse or teacher attendance rates. We have seen NGO’s that hold central government accountable (such as Equal Education that pressurize government spending on education), but we also need NGO’s that help citizens hold service providers accountable at a local level. 

What is needed is a more structured way to direct this growing discontent in a productive way to encourage improved service delivery.

There is growing research in economics on how community involvement can lead to improved service delivery. In health care project in Uganda, “report cards” were created on the quality of health care provision in communities. NGO’s then visited these communities, where (i) the report cards were disseminated and discussed; (ii) a “contract” was reached between community members and health care providers on how to improve health care provision; and (iii) measurable deliverables were agreed upon and a system was set up for community members to measure these deliverables. As a result of the project, health care treatment improved dramatically, leading to notable improvements in health outcomes (such as lower child mortality).

Primary Health Care and Community Monitoring

In Jonny Steinberg’s book on HIV/AIDS, “Three Letter Plague”, he follows the life of one young man who refuses to get tested. His life is contrasted with a project initiated by Medecins Sans Frontiere (MSF) and its champion, Herman Reuter, who believes that access to health care is the core problem, rather stigma over the disease. 

What I learnt most from the book was the work from the MSF project.

First, there should be a refocus of health care policy towards primary care. South African health care is vastly under-staffed and under-resourced. However, you don’t need to a doctor to diagnose and treat TB or HIV; you need a nurse or a trained volunteer. Furthermore a nurse is worth more in a rural clinic than in a hospital. The poor living in rural areas do not have access to hospitals. They can only afford to visit a hospital when they are very sick, by which point it is often too late. A lot of prevention and care could be done in clinics.

Second, there is great capacity for communities in South Africa to play a more active role in demanding good quality health care. In the health care project mentioned in the book, MSF initiated HIV/AIDS support groups. These support groups not only provided each other with support, but placed pressure on clinics to supply medicine and provide quality care. More on this, in my next blog

Service Delivery and Culture of Entitlement

The poor get poor service, not only because of bad provision and roll-out, but because the poor expect too little. 

A doctor friend of mine who moved from South Africa to UK recently remarked on the difference in patient behaviour between poor South Africans and the UK. In the UK, patients are more likely to question and challenge the doctors’ decisions. In South Africa, poor patients stoically accept doctors’ judgement. As a result, doctors in the UK are held more accountable by their patients. 

As another example, a South African friend failed to navigate the public health system when his wife got cancer. He was illiterate with no experience with hospitals. But more than that, he was intimidated. He was unwilling to push to receive the treatment he deserved. As a result, uptake is lower.

These examples show that improved quality and use of public service provisions is not only about management and access. It requires a better appreciation of the poor’s engagement with service providers. Accountability and uptake will be lower if clients expect too little. 

What explains this difference in behaviour? Maybe it is low expectations, learned from a history of bad service delivery. Maybe it is lack of confidence: asymmetric power relationships, which still remain after apartheid ended. Maybe the poor don’t believe they deserve good service. 

Annette Lareau (2011) argues that middle class parents cultivate in their children a sense of “entitlement”. They believe they deserve more and as a result get more. So, poor South Africans don’t have too much of a culture of entitlement, as many claim, they have too little. 

If a sense of entitlement is learned in the middle class household, then maybe public policy can do the same for the poor. Maybe it is possible to shift expectations through appropriate provision of information.  Ray (2003) argues that one poverty trap is a “failure of aspirations”. This could be applied to individual dreams (expectations of personal achievement), but also expectations of service delivery.