Accountability, Nutrition and Local Institutions in India
In contemporary governance discourse, accountability is found linked to almost every conceivable aspect of ‘good governance’ – from developmental effectiveness to empowerment. However, accountability, both as a concept and a strategy, has been reduced to rhetoric while large public programmes especially on health and nutrition continue to record dismal child nutrition outcomes even after six decades of democracy in India. Child malnutrition remains one of the most challenging public health and development issues in India. The article argues that local accountability processes and relationships between users and providers in a community are actual markers of service delivery as opposed to dominant practices of techno-managerial checks. Local institutional design shape actions of frontline health providers in service delivery which can explain differential child nutrition outcomes. The article is one of the original attempts in studying accountability in public-health service delivery from the prism of institutions in a developing democratic country like India.
Keywordsgovernance new managerialism public-service delivery rural development provider-user relationship
Rhetoric and paradox
India is hailed as the world’s largest democracy but there is something curious in the fact that accountability levels are so low here, despite the country’s strong democratic tradition (Dreze and Sen, 2002). There is rampant corruption, absenteeism, indifference, inefficiencies, or outright failure across public services and this paradox is inescapable (Posani and Aiyer, 2009). Although a young and vibrant democracy, India unarguably has the highest percentage of underweight and anaemic children (under-six years of age) in the world. An editorial of an Indian journal said forcefully, ‘[i]s it not time that the governments be held accountable for being incapable of reducing child deaths, whatever their immediate cause?’ (Editorial, 2002: 3688). Much of the public policy discourse holds weak accountability as one of the reasons for service delivery outcomes remaining poor in India (Posani and Aiyer, 2009).
Accountability has come to assume a central place in contemporary governance discourse over the last ten years, almost a mantra owing to increased donor attention on the idea of ‘good governance’ (Newell and Wheeler, 2006). In fact, in the 2014 general elections in India, the National Democratic Alliance, led by the right-wing Bhartiya Janta Party and incumbent Indian Prime Minister Narendra Modi won a sweeping majority by exploiting this notion of good governance in general and corruption in particular in their campaigns. As one of the pillars of good governance and sound institutions, accountability became predominant from three dominant perspectives – the World Bank’s (WB) perspective, followed by other multi-lateral agencies like the United Nations; the human rights perspective fronted by civil society and people’s movements and finally through the state’s perspective as many nation states, especially democratic regimes wanted to portray an image of transparency, trustworthiness, and responsiveness to its citizens. The rhetoric of accountability also made in-roads in every aspect of public-service delivery especially in health policy advocacy and human rights movements (Brinkerhoff, 2004; Potts, 2005).
Therefore the key question is how well people’s rights and social justice are being met with prevailing accountability institutions and processes in a democratic state. No wonder, being rhetorical and part of a paradox, accountability has increasingly become a contested idea.
‘Even fascist orders in Germany kept their governance ideals extremely transparent. But, that in no way reflected on the nature of the state at that time. Therefore, the wider understanding should be to treat Transparency and accountability not as an end in itself. The focus should rather be on the kind of society we envisage for ourselves and whether our nature of engagement and confrontation is adequate to bring about that change.’
Unpacking the contestation
There is no consensus among scholars on these typologies which most feel are not mutually exclusive but overlap considerably, thus creating a web of multiple, overlapping accountability relationships (Romzek, 2000; Roberts, 2002). Such classification of accountability is imperative to decode complexities of various mechanisms, tools, applications, relationships and their possible implications for democratic governance. It also puts into perspective the WB’s observation that the long route of accountability (political accountability) has failed people’s expectations thus stimulating efforts to create newer spaces of citizen engagement through shorter routes to accountability (social accountability). Non-state actors, mainly the civil society acted as a catalysts for these mechanisms through activities such as citizen report cards, citizen charters, community-based monitoring, Rogi Kalyan Samiti4 and social audits. To be fair, state provisions in India like the Right to Information (RTI) Act5 and the controversial Jan Lokpal Bill6 have also created newer spaces and instruments through which citizens can engage and scrutinize the state (Posani and Aiyer, 2009). Despite these newer spaces of accountability, their implementation has been sketchy, context specific and with mixed evidence on improvements in service delivery.
Experts call for grass-root level accountability by means of making health and nutrition programmes sites for contesting power (Sinha, 2006). But fundamentally, it is imperative to first unpack accountability relationships at the village level, something which has not been a topic of empirical scrutiny. There is a need to explain how communities cope in case of poor services and why they do not organize for collective action against the authorities. Also, most Indian studies on accountability seem to indirectly capture it through concepts like democratic decentralization and participation, transparency, corruption and the focus is rarely child nutrition. This article provides a glimpse of prevailing local processes of accountability at the frontline of service delivery and argues that these influence regional differentials in nutrition outcomes.
The state of Maharashtra with its capital city in Mumbai is the site of the study as it has the dubious distinction of being one of the most progressive states in India, yet high on income disparities and child malnutrition. A comparative case study research design in a deductive logic with the village as its unit of analysis was used. The three concepts of the study – institutions and actors, accountability processes, and service delivery outcomes on child nutrition were conceptually linked through adapting the Institutional and Development framework proposed by Polski and Ostrom (1998).
Political scientists believe that ‘the patterning of social life is not produced solely by the aggregation of individual and organizational behaviour but also by institutions that structure action’ (Clemens and Cook, 1999: 442). Also, the multi-disciplinary perspective of institutional framework (as opposed to purely sociological analysis) produces a rich understanding of the complex social policy situations (Polski and Ostrom, 1998). There were many institutional factors that can explain differential child nutrition outcomes in the two case study villages.
Growth chart: a tool for answerability?
One of the ways in which mothers can track on their child’s nutrition and elicit explanations from providers is through a growth chart. It was intended for the Anganwadi worker (AWW), a functionary of the child care and development center to communicate, educate, and counsel the mother if the child is underweight and required special care and feeding at home, in addition to supplementary nutrition received at the Anganwadi centres (AWCs). The growth chart is a standard tool for recording weight-for-age for each child, data which is aggressively collected by the ICDS. The question is, whether mothers consider them as a tool in their hands and if the ICDS considers it in same intent. In either case, it is not so because of which growth chart is the most under-emphasized and under-utilized aspect of ICDS.
In Village A, complete growth charts were found but there was no guarantee that they were shared with mothers. In Village B, growth charts were grossly incomplete and hence one can assume that they were never shared with the mothers. Mothers in both villages were unaware of the growth charts when asked during household interviews. This trend is common with the AWCs across India. The irony of the situation is that the ICDS meticulously records and extensively shares the weight and height of children for bureaucratic monitoring, but the same data is not shown to the mothers, defeating its very purpose. AWC in Villages B and Village A were started in 1983 and 2001 respectively and therefore there is no excuse for this ‘lack of awareness’.
One of the reasons for this trend lies with the NPM framework of managerial accountability that dominates the ICDS. For activities like sharing growth chart with mothers, there are no measurable indicators to monitor and hence it is blatantly skipped. When AWWs were asked, they claimed that the charts are shared with mothers when they come to the center for monthly immunization visits. In practice, the Auxiliary Nurse Midwife (ANM) from PHC leads in conducting immunization after which she counsels the mothers on infant care and health issues. The ANM is not mandated to share growth charts with the mothers during immunization.
Usually such a lapse is attributed as dereliction of duty by the AWW. This amounts to barking up the wrong tree. It is the institution and not the actor that has failed to create an opportunity for a mother to know about the growth and development of her child. It is owing to this that the ICDS has been reduced to a ‘dole’ as many experts have also voiced earlier, which is getting increasingly ineffective and counterproductive with even the poor opting out. This is one of the central reasons for disinterest and lack of community ownership in the ICDS programme.
Village health and sanitation committee: site for contestation?
At the village level, in order to create bottom-up accountability and community ownership on nutrition, health, and sanitation, the NRHM envisaged and institutionalized Village Health and Sanitation Committee (VHSC). Since child nutrition as a subject is not directly devolved to the Panchayati Raj Institutions (PRIs), it is not their mandate to demand accountability from the Anganwadi. But it is only through the VHSC that the AWC is accountable to the gram panchayat (GP) (Husain, 2011). In Maharashtra, within an year of launch of the NRHM nationally in 2005, the VHSC was renamed and re-organized as Village Health, Nutrition, Water & Sanitation Committee9 (National Rural Health Mission, 2006). Policy progression happened in Maharashtra well before the central Ministry of Health and Family Welfare acknowledged it in 2011 (National Rural Health Mission, 2011).
In practice, a VHSC was formed and functioned in Village A as a duplicate committee (as a water and sanitation committee already existed at the panchayat) and not as a part of the panchayat. In Village B its water and sanitation committee in the panchayat never included nutrition as its mandate and also did not form any separate VHSC. However, Village A stood out as there was a consensus between the GP and AWWs on the spending priorities of VHSC funds. Grants were used for buying chairs/tables for children; paying a honorarium to the Accredited Social Health Activist (ASHA); conducting health surveys; and sanitation. It was for this reason that AWC probably ‘functioned’ better in Village A than in Village B. But the fact that it was a stand-alone committee not under panchayat purview defeated its very purpose. The situation in Village B was the opposite where a VHSC was not formed and funds not utilized because of in-fighting between the sarpanch10 and AWW. One common observation in both villages was that actors, both providers and users were confused, as to whether the VHSC was a separate, stand-alone committee or the same as the water and sanitation committee of the GP. Therefore, while policy created a bottom-up formal mechanism of accountability for child nutrition services at village level, institutional processes allowed local actors to misinterpret it and with no sanctions levied on them if nutrition was still not considered at par with water and sanitation, as a political issue.
Monitoring and incentives: providers’ perspectives
An AWW in Village B responded to the question on filling the home-visit register, ‘we are supposed to home-visit mothers of five children every week. On my way to the AWC, I meet mothers on the way’. Researcher clarified, ‘You mean on the road?’ She replied, ‘Yes there itself she asks what food is being made at school and I also suggest her few things. That is counted as a home-visit’.
‘[i]f there is a child birth, we have to report its day, date and time to the PHC on the same day. So, nearing the delivery date, we keep following up with woman’s family or her neighbours if she delivered. Even if the woman is at her mother’s place, we still have to report as she would eventually return back. We get Rupees 10 to report one such case. But for these 10 Rupees we have to make numerous visits, phone calls, give a written note and get it signed by the ANM and then we get Rs. 10. It is not worth the trouble.’
This kind of accountability circumvents actual services that are mandated in the programme. On being asked if the providers share their work with the GP or to the parents of the children, both the villages had a different scenario. Providers in both villages agreed in principle that they too are answerable to the people but do it through one-on-one interactions. Surely, this is not a proxy for institutionalized account giving. Also, most felt that although they work for the people they are not accountable to the GP. Most of them were unanimous on one issue, that if the GP does not call them for meeting, they do not go. The AWW in Village A shared that they are present in the gram sabha meetings and also share their problems ‘sometime’. Another AWW from Village A was of the view that although they have a voice in the GP, overall it is the GP which does not take interest in Anganwadi’s work. In Village B, gender and power dynamics resulted in non-participation. The AWW from Village B commented, ‘Gram sabha happens but I have never gone and they too have never called me. As it is, it is only for men, women do not go there’.
While there were opportunities for dialogue between the providers and the community in Village A, the community participation link was extremely weak in Village B. Political capability of actors and different histories of political empowerment in the two districts are macro factors which cannot be ignored. Satara has a historical trajectory of providing most chief ministers of Maharashtra. Literature dominated by NPM has often critiqued heavy workload of AWWs in comparison with their honoraria, as an impediment to the effectiveness of the ICDS. Historical evidence on the role of community workers show that they are not qualified but locally hired and trained personnel who can work in remote areas, costs less for large scale programmes, and are not prone to absenteeism (Joshi, 2006). Therefore demands for induction of these workers as government employees cannot make them more efficient or accountable to the community. Clearly, in both cases, providers’ actions are largely guided by misconstrued institutional processes and not by individual discretion.
Anganwadi workers in both villages were rated poorly which was much lower than ASHA or ANM. This seems to be surprising given a fact that the AWW is responsible for early childhood care and education of the children in village. Her position has the potential to command high respect and trust from the local community. However, as data revealed, the AWW is the least popular and quite equally so in both villages. Although both the rich and the poor access these services, the poor, with a lower capacity to articulate their demands remained disengaged while the middle class11 and the rich, exited out. Interviews with mothers especially from middle and upper classes in both villages pointed to a reverse kind of discrimination. According to the them, non-poor families are subtly discouraged from using ICDS and PHC services through practices like not sharing information, not visiting them at home or following-up if their child is not attending clinic, and when they do visit, they are not assisted.
The poorest households chose private health services in Village A as compared with those in Village B. Clearly, the private health sector was much more developed around Village A owing to the comparatively better socio-economic development of the district, making it viable for private providers to operate and make profits. It is worth noting that the PHC for Village A was within a 3 km distance and according to its Medical Officer, one of was recognized as the Best PHCs in 2011. It is evident that mere supply of public-health services in terms of access and quality may not be the only factor that can guarantee their use by rural population. Exit of the rich serves the interests of the providers in preventing additional work load within the same remuneration. It is a common feature of public services (Humphreys, 1998). Therefore institutional structures that build common interests between the poor and the rich are more likely to lead to quality improvements that are sustainable in the long run (Kumar, 2007). Existing policy on child nutrition needs to prevent exit of the middle and rich households as much as it needs to include disadvantaged social groups.
‘Just as it is impossible to know when a fish moving in water is drinking it, so it is impossible to find out when government servants in charge of undertakings misappropriate money’. Kautilya in Artha-shastra (300 B.C) (Premchand, 1995).
Weber’s theory of bureaucracy mentioned that the responsibility of public servants is restricted to the execution of orders given by the legitimate power (Aiyar, 2012).
In this paper the concept of accountability is taken as a relationship between an actor (powder wielders like politicians or service providers) and a forum (user, group of users, community) in which the actor has an obligation to deliver services. Forum can pose questions to actor who needs to explain or justify his or her conduct. Forum can pass judgment and the actor can face consequences.
Rogi Kalyan Samiti is loosely translated as Patients’ Welfare Society which seeks direct involvement of the users (people) and service providers (doctors, paramedics) in running public hospitals. It aims for partnership of all concerned actors at the local level to raise funds for the upkeep of public hospitals and, in turn, ensures their participation in the management of health services. It is also referred to as a Madhya Pradesh scheme of Public Private Partnership (Kumar, 2003).
The Right to Information Act was implemented in 2005 with an aim to empower citizens to probe working of their government towards participatory democracy. It made people aware that they have a right to access information from any public department, a right that is legally enforceable with provision of penalties for illegitimate delay or refusal of information (Niranjan, 2005; Singh and Rajakutty, 2007).
Jan Lokpal Bill, also referred to as the Citizen’s Ombudsman Bill, is an anti-corruption bill drafted and drawn up by civil society activists in India seeking the appointment of a Jan Lokpal, an independent body to investigate corruption cases. The demand of Lokpal was a result of a civil society campaign called India Against Corruption, led by Gandhian crusader Anna Hazare. The Indian Parliament and government of India passed its own version of Lokpal Bill in December 2013.
ICDS is a universal programme, recently enforced as a legal entitlement under The National Food Security Act, 2013 enacted by the Indian parliament on September 12, 2013. The act brings under one umbrella several existing and new entitlements aimed at providing food security – ICDS, School Mid Day Meals, Public Distribution System, Rural Employment Guarantee, Maternity entitlements and social security pensions. Under this act, the state is bound to provide an age-appropriate ‘meal’ which meets specified nutritional norms, free of charge to children under six (specially malnourished children), pregnant and lactating mothers through the local anganwadi, as an entitlement for people to live life of dignity (Ministry of Law & Justice, 2013).
Block is a district sub-division which represents an area for which administrative plans are implemented.
A sarpanch is an elected head of a village level statutory institution of local self-government in India called Gram Panchayat (GP).
To assess the economic class of the households in the study, a proxy indicator of households’ asset ownership was used to ascertain their economic status. Assets of rural households were divided into categories like land, buildings, farm equipment, livestock, vehicles, household items, and so on. and each category comprising of comprehensive list of items, their number or quantity and current approximate price (in Rupees). Once each item had a value, all asset values were summed up to get one consolidated value of asset ownership per household. Asset ownership of a household between 0–5 lakh was named as poor asset class; 5–10 lakh as lower middle; 10–20 lakh as middle; 20–50 lakh as upper middle and 50 lakh plus as rich asset class.
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