Citizens’ Priorities Must Dictate Development Initiatives, By Temilade Sesan

The marble plaque commemorating the founding of the primary health centre in Oboto, a peri-urban agrarian community in Ondo state, Nigeria, declares the facility open ‘to the glory of God and the benefit of mankind’.

In the decade or so that has elapsed since its opening, the health centre has found it particularly difficult to deliver on the latter part of its mandate, as even the most cursory of visits to the facility is likely to reveal.

The lone patient ward in the health centre – a small but clean affair housing three modest but functional hospital beds complete with mosquito netting – is very rarely occupied.

Demotivated health workers sit facing empty chairs in the consultation area when they are not sleeping off their boredom in the adjoining staff room, with only a family of goats to keep them company most of the time.

The vision of reaching large swathes of mankind in the community with the modern health services and technologies on offer seems to be slipping away with the passing of each sluggish day.

The uplifting proclamation on the facade of the Oboto primary health centre is illustrative of the promise that technology has historically held out for development in poor countries. Yet the reality is often far from what is promised.

There is a long and varied history of deceptively simple technologies, introduced in response to poverty and deprivation in the global South, gaining little acceptance or use by target groups.

From shiny improved cookstoves to newly provisioned basic health centres, the rate of abandonment of promising technological ‘interventions’ by people who are seemingly in dire need of them is nothing short of baffling to most observers.

The community health centre in Oboto is one such case. It is one of thousands in a nationwide network of government-run primary health-centres (PHCs) set up to provide basic health care at grassroots level.

In response to prevailing low levels of PHC functionality across the country, the World Bank in 2011 initiated a performance-based financing scheme in partnership with the Nigerian government in 33 primary health-centres including Oboto. In Oboto, the scheme was partially successful in its own terms, but failed in its ultimate goal of getting more people to patronise the centre.

Research commissioned by the World Bank identified a number of factors that contribute to the low usage of the health-centre.  Of these, variable drug pricing comes across as fundamental.

The health-centre receives periodic consignments of free drugs for pregnant women and children under five –under the National Health Insurance Scheme. But these are typically irregular, with dispatches as infrequent as once a year or as many as three times in the same period. Not surprisingly, this arbitrary administration has generated a negative public perception of the centre’s effectiveness.

More recently, the scheme administrators have provided a steady supply of drugs at the health-centre. But this has come at a price as  clients are now required to pay for those drugs. Most people have responded by simply not turning up at the centre for treatment, so that the facility is still largely deserted even though it is now regularly stocked with essential medicines.

The exceptions to this are the couple of times a year when drugs are made available free of charge for a few days at a time: at those times, clients actually visit the centre in droves, and the consultation area is transformed from a sleepy space into a bustling hub of activity. This suggests that low client patronage in Oboto is not due so much to a mistrust of modern medicine on the part of the people (as has been suggested elsewhere) as it is to a general reluctance among citizens to pay for drugs at a public health facility.

This experience is consistent with the finding from recent research conducted by MIT’s Poverty Action Lab that charging even the tiniest of fees for public health services can lead to dramatic reductions in poor people’s demand for those services.

The same citizens sometimes bypass the primary health-centre to pay far higher sums (so out of proportion with their meagre means that they often have to spread out payment over several months) at oftentimes specious private ‘clinics’. However, this might be because charging for drugs in a public facility is at odds with a shared understanding of what a public service is supposed to represent.

Health workers at Oboto view the institutionalisation of an effective free drug scheme as the one guaranteed route to raising community patronage at the primary health-centre. The World Bank-funded  intervention in the centre might have looked different  if this fundamental insight had been elicited and applied to project planning in the first place. This illustration highlights a couple of lessons for development research in general:

• First, external interventions need to start by asking open questions of local people;
• Second, responses to those questions need to be interpreted in light of the social circumstances in which they were generated rather than in line with any set of predetermined principles.

In sum, development interventions financed by Northern organisations are typically closed to public consultation at the planning and decision-making stages. But their impact on local communities in the South can be more meaningful by engaging citizen representatives at an early stage. This could have the important effect of strengthening local democratic processes, potentially paving the way for the kind of broad-based citizen participation needed to keep developing country governments accountable in the long run.

Some Northern-led development organisations are already taking this early engagement approach, with slow but sustainable results.

One example is Reboot, a US-based social enterprise that conducts ethnographic analyses of developing country contexts to better understand their peculiar characteristics before designing and implementing interventions with people in those contexts.

It may be difficult for even the most enthusiastic proponents of responsive intervention to justify the slow pace of change that comes with this approach – after all, even the most rudimentary improvements in people’s conditions can mean the difference between life and death.

However, a long-term commitment to identifying the priorities that, in Amartya Sen’s words, people ‘have reason to value’, could enable more precise targeting of scarce resources and broaden access to the interventions that result from the process. That is a goal worth aspiring to for the benefit of humanity everywhere.

Dr. Temilade Sesan a development sociologist is an expert in energy poverty and gender issues. Her doctoral research investigated international efforts to promote improved cookstoves in Nigeria and Kenya; papers from this work have appeared in Energy Policy, World Development and Progress in Development Studies. She is currently at the Centre for Petroleum, Energy Economics and Law, University of Ibadan, Nigeria.