Project impact
In keeping with SAHAYOG’s, the CBOs’, and MSAM’s respective missions and our research questions, we group our findings and discussion into three broad categories: (1) impact on empowerment, (2) impact on the incidence of informal payments and related issues, and (3) macro- and micro-contextual determinants of health system responsiveness.
We use Kabeer’s [
52] concept of empowerment, “the process by which those who have been denied the ability to make strategic life choices acquire such an ability” (p. 1). Making choices entails exercising three inter-related capacities: resources (preconditions), agency (process), and achievement (outcomes) [
52]. For the purposes of this study, we focus primarily on the knowledge components of resources, secondarily on the relationships component of resources, and on the negotiation, voice, and mobility elements of agency. Achievements refers to the accomplishment of desired goals, namely the cessation of demands for informal payments and other improvements in the inter-personal and clinical quality of care. We address resources and agency here, and describe achievements in the section describing MS, MA’s impact on the incidence of demands for informal payments.
As documented in earlier studies, over the course of their approximately ten year engagement with MSAM, MSAM women, particularly those who had been members for a long time, have gone through repeated consciousness raising processes, as they learned about their rights and entitlements and successfully addressed priorities in multiple domains, such as distribution of subsidized rations and the minimum rural employment guarantee. As low caste, poor women, new members often initially did not think of themselves as rights holders, or as having the “right to have rights” [
41,
53]. This self-perception evolved over time as MSAM women came to believe that health and social outcomes are not due to chance, but are matters of social justice which the state has the responsibility to address [
41].
In interviews and FGDs comprising the current study, SAHAYOG and CBO staff and MSAM women themselves emphatically communicated the multiple ways that their resources and agency had increased. They described a general sense of empowerment and loss of fear from their involvement in MSAM, as well as gains in knowledge and confidence specific to the health sector. Sometimes, they discussed MS, MA specifically, but more often, they referred to their engagement in MSAM in more general terms (i.e. not limiting themselves to the life of the MS, MA project).
We have abandoned our fear from the day of joining the Forum [MSAM]. We were afraid of speaking out in the past. Now, we can talk to the Chief Medical Officer and speak from the stage using a microphone… our fear is finished now. (FGD with MSAM women)
Women generally attributed their increased agency to the knowledge resources they had gained through MSAM.
When they demand money, we say that it is against the rules. Then, they realize that we are the members of MSAM. Those who are not members of MSAM cannot speak. They do not have information. (FGD with MSAM women)
Many women exhibited agency in their willingness to put themselves in uncomfortable, adversarial, or risky situations to assert their knowledge and claim rights. Several CBO staff and MSAM members described situations where women faced down threats in their refusals to make informal payments. MSAM women reported a variety of menacing situations, including providers threatening physical violence, mobilizing political allies against the family making a complaint, filing a false legal complaint against the woman concerned, being rough with the laboring woman and/or the newborn, and, denying the woman care.
Since they have to take money from us, they behave properly. They misbehave only if you refuse to give them informal fees. The enmity starts when we refuse to bribe them. They refuse to prepare a record of treatment if we do not pay informal fees… People do have a fear that if they refuse to make informal payments, doctors may kill our patients by poisoning them. (FGD with MSAM women)
Our data did not reveal any allegations of actual poisoning (just the fear of it), but we did hear multiple stories of women who identified as MSAM members being denied care, suggesting that providers punished those who tried to claim their rights. Sometimes women were able to negotiate to receive care anyway, sometimes not. For example, an MSAM leader reported accompanying her laboring daughter-in-law and being recognized as an MSAM leader by the Medical Officer in Charge. He refused to provide care, and the MSAM leader countered that she was going to call his boss, the Chief Medical Officer; the provider relented.
Many other MSAM women referred to this relational resource of access to frontline providers’ “bosses,” whom they had met at dialogue events or contacted in the process of making complaints.
SAHAYOG and CBO staff emphasized that this improved knowledge resources and agency resulted from a long-term process, and was not just the result of the MS, MA project. MSAM members, too, understood changes in their resources and agency in the context of their longer-term engagement with MSAM.
It has been ten years since we are associated with the organization. It was essential to join it…. We learned how to register our complaint in Lucknow through mobile phones. We also learned about human rights. Initially, we were fearful but now we can threaten the ASHA [community health worker] and ANM [frontline midwife who supervises the ASHA] in the name of registering a complaint. (FGD with MSAM women)
Empowerment does not occur solely in relation to the health system; MSAM women claimed their rights in a dynamic context of gender, caste, religious, and political relations. There is widespread agreement in the empirical literature on social accountability and participation that women’s political capabilities are mediated by gendered social norms within the household and the community [
32,
54,
55]. Although most of the discussions in our interviews and focus groups centered on interactions with the health system, MSAM women regularly referred to these wider social norms. They indicated that the empowerment they felt was not just vis-à-vis the health system. Some – though not all - noted that they felt liberated from husbands and/or mothers-in-law who were opposed to their mobility and to their engagement in political matters outside the home.
Family members discourage us. When I came to the meeting for the first time, I had informed my husband. But, when I went back, he slapped me. When I argued, he started beating me, and kicked me out of the home. Then some of the members went to my home and convinced him. (FGD with MSAM women)
In sum, in our research sites, MSAM women manifested increased resources and agency; they developed this over a time frame well before MS, MA began, and they sometimes fought to claim their rights despite significant opposition.
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Impact on the incidence of informal payments and related issues
Kabeer describes resources, agency, and achievement as indivisible components of empowerment [
52]. SAHAYOG and the CBOs explained that they felt that increased knowledge and opportunities to use that knowledge were important goals, but they also realized that failure to impact the incidence of demands for informal payments (achievement) would undercut community engagement, and ultimately empowerment. In FGDs, MSAM women agreed among themselves that significantly reducing the frequency of demands for informal payments was a key objective.
MSAM women described being asked to make informal payments to receive maternal care, to see the newborn, to be discharged from the facility, to take the ambulance to the facility to deliver, to receive the JSY check (a conditional cash transfer for giving birth in a facility), and for the labor room to be cleaned. As summarized in Table
1, a review of all cases reported over the life of the project indicated that a total of 2850 reports were made to the hotline for several reasons.
Table 1
Summary of MS, MA cases from January 2012–December 2016
Bribe for admitting the patient, treatment or during delivery | 23 |
Money asked for medicine, gloves, soap | 21 |
Money asked for ambulance service | 20 |
Money asked in order for the patient to receive the JSY cheque | 15 |
Bribe for examination | 14 |
Money asked for blood or operation | 7 |
Almost 72% of all payments reported to the hotline were for more than 500 rupees. Many were asked to procure from outside pharmacies medicines that the health facility was mandated to provide. SAHAYOG and the CBOs believe that in many of these cases, private pharmacies provide kickbacks to the prescribing providers – a phenomenon that has been widely reported in India [
56] though in some cases the health facility may actually be stocked out of the drug in question.
SAHAYOG, the CBOs, and MSAM women successfully educated or convinced some state, district, and facility staff about the frequency and impact of informal fees. As a result of what they learned and/or the pressure SAHAYOG and the CBOs brought, our data indicated that these officials made administrative allowances to address informal payments, such as issuing orders mandating discussion of MS, MA data in regular meetings, and mandating CBO participation in various forums. For example, the Uttar Pradesh NRHM Mission Director issued a letter asking that Patient Welfare Committees discuss MS, MA data at their meetings. Chief Medical Officers reissued this letter to Medical Officers in Charge of health facilities, asking them to ensure implementation at facility level. One District Program Manager reported that the facilities in his jurisdiction outsourced diagnostic tests to prevent demands for informal payments for laboratory tests.
According to CBO and MSAM women, district and block level dialogues resulted in short-term (2 week – 3 month) reductions in demands for informal payments from MSAM and non-MSAM patients, as well as improvements in other domains that had been raised at the dialogue. When asked what factors precipitated these improvements, the CBO and MSAM women widely agreed that these changes were more likely to occur when many women attended the dialogue, as well as when higher-level officials attended. Improvements went beyond informal payments to also include better (more timely and/or free of charge) ambulance service in rural areas; the installation of solar lights and generators in remote facilities; cleaner facilities; new equipment in maternity wards; and the provision of free food to in-patients, as stipulated by policy. Multiple interviewees from different stakeholder groups recounted that some health system managers asked frontline health providers to explain why MS, MA data showed persistent demands for informal payments. In some cases, hospital staff reportedly returned money to patients. Due in part to the public nature of the district or block dialogues, the CBOs explained that they could shame providers into participating in the dialogues and to following through on commitments made during the dialogues.
The hotline also included an emergency number for urgent cases; this emergency line resulted in immediate aid for callers. The emergency number was staffed 24 h per day by CBO employees. The interviews and FGDs revealed many examples of emergencies being addressed, often because the CBO representative on call then contacted someone above the offending provider in the hierarchy. For example, a woman being denied a blood transfusion, a skeptical woman being told she needed an urgent cesarean section and she needed to pay for it, and multiple women being denied care because they were allegedly presenting at the health facility “too late” in their deliveries, had their problem addressed immediately after contacting the emergency line. SAHAYOG and CBO staff reported that this immediate responsiveness helped to maintain community support for the project.
SAHAYOG staff explained that because the project entailed regular CBO and SAHAYOG interactions with health sector officials at block, district, and state level, the CBOs and SAHAYOG enjoyed greater visibility and cooperation vis-à-vis official structures. SAHAYOG input was regularly solicited by state level health authorities. SAHAYOG employees reported that they felt that most policy-makers perceived SAHAYOG as an organization providing relevant, authentic data from the grassroots.
Against this backdrop of increased knowledge and commitment at the mid and upper levels of the state health system, public dialogues, and increased SAHAYOG and CBO engagement in policy-making and policy monitoring, interviewees of all types reported that MSAM women who asserted their rights were mostly able to avoid making payments, though some faced retaliation.
When I took my daughter-in-law to the hospital… the staff demanded 500 rupees and I was asked to go and buy a medicine from outside. When I scolded them, the Auxiliary Nurse Midwife [ANM] started arguing and said that things may go out of stock anywhere. Then I replied that you should take care of the things going out of stock and should bring them before they are finished. I also made a telephone call to the CBO… [the ANM] refused to talk [to the CBO] but she also abandoned her demand for money (FGD with MSAM women)
MSAM women and CBO representatives explained that non-MSAM women accompanied by MSAM women (or by a representative of the local CBO) were also largely able to avoid payments. These changes spilled over to the general population in limited contexts; for example, FGD participants reported that lower caste women – MSAM members or not - were now less likely to be asked to pay for the cleaning of the labor room after delivery, a practice that had been routine. As testament to MSAM’s informal regulatory power, in some facilities, health facility staff tried to obtain explicit MSAM member support for urgent patient referrals, in order to show that the transfers were needed and consensual.
However, despite the reported facility-level changes following dialogues, SAHAYOG and the CBOs’ increased participation in policy discussions, and MSAM member ability to refuse to make informal payments, MSAM, CBO, and SAHAYOG representatives agreed that they did not accomplish their ultimate goal of reducing demands for informal payments on a population level; there was little system change. The CBOs and MSAM reached this conclusion by informally asking women about payments after they left health facilities, and by discussing what they heard from friends and neighbors at MSAM meetings. In an FGD, an MSAM member described this lack of progress:
Many of us went to the hospital, we demanded that informal money should not be taken from us. We had several meetings on these issues. Staff say that they will not take money again but things go back on the same track once again. Doctors have assured us many times that they will punish those who demand money. But, everyone is a culprit there. (FGD with MSAM women)
Participants summarized the situation similarly at an FGD for CBO members. Those who know their rights can sometimes avoid paying, but others cannot:
Interviewer: Is there any change in the situation? Do such incidents occur less now?
Respondent 1: Staff cannot take money from those who know their rights and entitlements. Such people fight and do not pay informal money. Otherwise, they demand [money] in the name of celebration...
Respondent 2: Those who fight until the end can save their money, but not all of us are able to do that. (FGD with CBO members)
Reporting to the hotline went down over time; SAHAYOG and CBO staff explained that this was likely because the campaign seemingly had little impact on the likelihood of women being asked to make informal payments. The campaign was based on the premise that the data could foment system level change. Not seeing improvement, women were less motivated to report, and were less optimistic about their ability to effect change. Many expressed the following sentiment in interviews and discussions:
We are now tired of attending dialogues and complaining. Everything becomes the same after a temporary change. (FGD with MSAM women)
As SAHAYOG and CBO staff explained in interviews, decreases in reporting gave the government an excuse to claim that demands for informal payments had decreased. The hotline began to slide into irrelevance, as fewer women reported or were motivated to do the risky work of complaining about informal payments.
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Macro and micro contextual factors shaping state responsiveness
Despite their increased knowledge and relational resources, agency, and past achievements in many domains, such as in securing better access to rations for the poor, ensuring the regularity of Village Health and Nutrition Days, integrating MSAM members into Village Health and Sanitation Committees, and securing greater access to the minimum employment guarantee, MSAM women had fewer achievements in the domain of informal payments [
57]. Health providers and the system overall were only partly responsive to demands regarding informal payments.
The contextual factors shaping state responsiveness are less explored than the community dynamics of social accountability, though response is germane to the success of an effort and to continued engagement from the community [
17,
31,
58]. In this section, we discuss macro and micro features of the context that seemingly influenced health system responsiveness related to informal payments. The contextual factors that arose from our data are broadly similar to what has been identified as contextually relevant in other settings, including “broad features of the political economy” [
28,
59]. Our data revealed relevant factors that are manifest at national and subnational levels, including caste hierarchies, provider commitment to ending informal payments, the embeddedness of informal payments in the health system, human resource scarcity, the overlapping private interests of pharmaceuticals and providers, differences in regional development, and individual influence on the project.
Caste
Many MSAM, CBO, and SAHAYOG interviewees indicated that lower caste women had fewer opportunities to exercise agency and to realize achievements than higher caste women, as decision-makers did not give equal consideration to the rights and opinions of lower caste women. As explained by a Dalit MSAM woman:
If N [a higher caste woman] complains about something, people are not going to say anything. But, if I make the same complaint they will call me all sorts of names and hurl abuses at me. (FGD with MSAM women)
None of our interviewees or FGD participants suggested that caste make up per se explained differences between project sites. However, CBO and SAHAYOG staff explained in interviews that lower caste and scheduled tribe women were at a disadvantage in all arenas of rights claiming, and were generally more likely to be asked to make informal payments, because health providers perceive that lower caste women have less resources and agency. Moreover, the participants in one FGD indicated that heterogeneous MSAM groups may have been less durable. Some lower caste members of one MSAM group explained that they no longer met without explicit CBO facilitation and support. They stated that the elected head of this group was lower caste, and upper caste women would not attend meetings she called without the external coordination and legitimacy conferred by CBO engagement.
Provider commitment to ending informal payments
As noted, there was some evident high-level commitment to decreasing informal payments at the state level, as NHM leadership expressed their support for the project and asked for SAHAYOG input into multiple policy-making processes. This commitment was buttressed by changes in the political context, as, shortly after the project began, newly installed policy-makers relaxed restrictions on NGOs and focused more resources on fighting corruption. When district officials were asked why this central level commitment did not engender commitment among frontline providers, they referred to technocratic and logistical barriers, such as lack of required computer skills to look at the MS, MA website and lack of time. District officials, SAHAYOG, and the CBOs also cited poor communication regarding policy priorities between the central level of the state and districts. However, our research also suggested that some frontline providers and medical officials seemingly did not change their behavior because they did not agree that informal payments were deleterious. About half of the district officials and senior managers interviewed disagreed with the premise that informal payments were problematic, stating that it was acceptable for service providers to demand informal payments, as poor women received a conditional cash transfer if they delivered their baby in a health facility, and, if women were not asked to pay, they would overuse medical care. Several claimed that women’s expectations were too high, or, that if women did not want to make informal payments, they should simply refuse to pay them.
Interviewees and focus group discussion participants offered other reasons for the persistence of informal payments, with many interlocutors of all types converging on one key point: there is a complex nexus of financial exchanges that few providers and managers are motivated or able to change. Informal payments are deeply embedded in the health system, such that it may be more difficult to obtain responsiveness in this domain than in the other areas SAHAYOG, the CBOs, and MSAM had worked.
Among providers, several phenomena feed the nexus. First, as has been detailed in the peer-reviewed literature, interviewees of various types explained that many providers pay for their position [
60‐
62]. Providers thus wanted income from informal payments in order to pay to stay where they are, or to pay for a more desirable posting. Second, interviewees from all stakeholder groups speculated that providers who levied informal fees were financially indebted to their superiors or to other decision-makers, perhaps for obtaining a post or for superiors’ overlooking transgressions. Third, the nexus could expand, neutralizing potential whistle blowers or opponents. For example, SAHAYOG and the CBOs explained that they initially assumed that Accredited Social Health Activists [ASHAs] would be natural allies of MSAM and MS, MA. However, ASHAs rarely showed themselves to be allies, and some SAHAYOG and CBO staff concluded that the principals of the nexus co-opted ASHAs by allowing them to charge their own informal fees. We did hear scattered reports from SAHAYOG, CBOs and MSAM women of ASHAs preventing CBOs from entering villages to conduct awareness raising on entitlements and the MS, MA project. ASHAs may have been more vulnerable to co-optation because the amount of compensation they received from the government had decreased in recent years; several CBO and MSAM respondents reported that they thus became more willing to seek payments directly from women.
Mid and senior level managers claimed that because of the nexus, their ability to sanction the providers demanding payments was limited. The nexus was not confined to a health facility; financial relationships often related to broader political dynamics in the community. Thus, political power could be deployed to maintain the status quo. Indeed, political patronage was ubiquitous in discussion, with multiple managers claiming that they were unable to sanction employees who were below them in the hierarchy because these individuals had political connections they could use to get the manager transferred. Providers who had lived in a region longer reportedly had stronger political connections, making them more impervious to discipline. The nexus seemingly had the effect of flattening the hierarchy for most (not necessarily for those with the least power, such as ASHAs) such that everyone owed everyone something; as one district official in Azamgarh described, “everyone has a jack” he can deploy to avoid accountability. Some managers reported disciplinary workarounds, such as “managing on the inside,” or resolving the problem by reaching a compromise with the employees concerned – sometimes by dividing up the spoils.
MSAM women, in contrast, had few political connections, and few “jacks” to deploy.
Interviewer: Is it more important to have a good connection with some influential people than complaining?
Respondent: Yes. Nothing is possible when you do not have a strong connection. (FGD with MSAM women)
Human resource scarcity
Officials and managers stated that the nexus was even stronger in a setting of very limited human resources. For example, one district official explained that he was not in a position to punish a doctor who violated policies in the understaffed hospital. Providers in such contexts are in a strong negotiating position. A District Program Manager from Azamgarh elaborated more fully:
We cannot take direct action against the staff, as the number of staff is already less than what we require. If we did [take action], the services which are available today would not be available tomorrow. They have built up a strong nexus among themselves. We cannot take any action against any of them; if they are suspended for even two three days then we won’t be able to provide even basic facilities to our clients. We could have taken action only if there were a good number of doctors available there. (IDI with District Program Manager)
While there was widespread agreement among different types of interviewees and FGD participants that a nexus existed and that this nexus nurtured informal payments, we interpret manager explanations of why they were unable to address informal payments with some skepticism. SAHAYOG and CBO staff speculated that managers try to attribute informal payments solely to lower level staff in order obscure their own role in it. Some managers may benefit from informal payments indirectly or directly, or they may engage in their own corruption that health providers know about, so they do not dare to stop frontline providers. A limited number of managers substantiated this view, as they explained that demands for informal payments at the point of service was a visible form of corruption that patients saw, but that it was the last link a long chain of corruption. Informal discussions during participant observation confirmed this view. Providers noted that there was corrupt behavior throughout the system; demands for informal payments were among the more visible manifestations of corruption.
Overlapping private interests of pharmaceuticals and providers
The nexus also applied to the prescription of medicines from outside pharmacies, which was one of the most ubiquitous forms of informal payments. To decrease patient opposition to purchasing these drugs, it appears that providers fed widespread myths that government-supplied generic medicines are of poorer quality and less effective. MSAM members and families of patients encountered during the participant observation reported that they were willing to purchase ‘quality’ medicine from the outside. While we did not explore this angle in our research, recent research in India suggests that pharmaceutical companies also propagate this false narrative, while independent testing reveals that government supplied generics are of comparable quality to branded medications [
63].
Differences in regional development and individual influence on the project
The findings regarding regional differences and individual influence are intuitive, so we do not describe them in-depth here. The key point is that there were regional differences in project uptake and buy-in, with the more geographically remote district seeing less impact. Finally, some successes in reducing demands for informal payments were partly attributable to individual people, both within the CBO and the Indian Administrative Service, the professionalized bureaucracy of India.