Citizens, health and governance

Prime Minister Imran Khan recently launched the Pakistan Citizens’ Portal in an attempt to promote citizen-centric governance. The portal is currently available as a mobile application that allows for complaints to be made in 20 different areas, including health.

It is set to be integrated with a toll-free call number and citizens will also have the option of relaying their grievances and concerns to the government via email, letters, and a web portal. It is an integrated platform connecting citizens to all organisations (approximately 4,000 government offices) both at the federal and provincial levels, with each province’s chief secretary responsible for ensuring that all complaints are addressed in a timely manner.

However, as impressive as the scope of this portal may be, there are some questions about its potential applicability based on Pakistan’s previous experiences with engaging citizens, particularly in terms of healthcare.

This initiative could be a welcome addition to the health sector in Pakistan where feedback from citizens is, at best slow, and, at worst, doesn’t reach the decision-making authorities. The current mechanism for feedback in healthcare is through elected representatives, who are responsible for raising health concerns with the minister for health. An additional route for citizens to directly voice their health concerns and provide feedback on the care they receive at government facilities could become a powerful tool for accountability, and potentially play an important role in Pakistan’s health-systems governance.

It should be noted that the citizen’s voice and accountability is not a novel notion within the health system in Pakistan. Previous attempts by provincial governments, like the Citizen Feedback Monitoring Program (CFMP) in Punjab; complaint cells in provinces, and Khyber Pakhtunkhwa Citizens’ Portal included solicited citizen voices on health-system functioning. The aforementioned attempts included robocalls, text messages, call centres, emails and mobile applications as the key methods of bringing forth the voice of citizens. For example, under the Citizen Feedback Monitoring Program in Punjab, members from a call centre would call a sample of patients from secondary-care hospitals and ask questions about whether they had received medicines, paid for tests, and were satisfied with cleanliness standards. The data on medicines was compiled and reported to the secretary, the provincial health minister and the chief minister for a complete feedback loop.

In addition to government interventions like this, donors and NGOs have also initiated projects that focus on using feedback from citizens to improve governance in healthcare. For example, two such interventions are the Empowerment Voice and Accountability for Better Health and Nutrition (EVA-BHN) by DfID in Punjab and Khyber Pakhtunkhwa, and the Citizens’ Voice Project by Usaid in Sindh. For instance, the EVA-BHN project has identified and trained community groups who take feedback from citizens and report either directly to facilities or through district advocacy groups.

Though laudable in their own right, these modes of bringing the citizens’ voice to improve governance, both from government and donor organisations, have suffered from limited access, the lack of a legal framework for their enforcement and legal and institutional frameworks that promote accountability, and limited knowledge on the part of beneficiaries.

In particular, the government mechanisms are also prone to be politicised by either the government or the opposition. In some cases, concerns have been raised over the privacy of data. Any holistic mechanism aimed at promoting citizens’ voice also has to contend with the idea of citizenship and empowerment.

Notwithstanding the hundreds of thousands of refugees in Pakistan who don’t have a formal status in the country, even those holding national identity cards aren’t aware of their rights and lack the basic technical know-how to operate app-based services. This is critical to breaking the current norm of the patron-client relationship between policymakers/service providers and citizens.

Even when it will be expanded beyond the current app to a call centre and other digital platforms, the Pakistan Citizens’ Portal will be prone to the aforementioned problems. While there are publically available evaluations for both programmes highlighted above, the Citizens Feedback Model in Punjab and the EVA-BHN project by DfID, there is little to suggest that this feedback has been incorporated for health-systems governance and service delivery into the Pakistan Citizens’ Portal.

Overall, the initiative has the potential to become an important institutional mechanism for much-needed accountability in the health system. However, the absence of a strategy document or roadmap for the Pakistan Citizens’ Portal raises important questions regarding accessibility, knowledge dissemination to a technologically-disenfranchised populace, inclusivity, and the legal frameworks of the initiative.

Some of these questions could perhaps be answered by gauging previous attempts at engaging citizens to improve governance in health. This leads to our main question: what were the lessons from previous attempts and how have they been incorporated in this portal? While only time will tell the impact of such intervention, without learning from the past it currently stands the risk of becoming a political slogan with limited impact

The views expressed in this article are those of the writers and do not represent their official positions.

Faraz Khalid is a health systemsconsultant at WHO. Muhammad Usman Khan is a freelance health policy analyst in Islamabad.

Wajeeha Raza is a research fellow at the Aga Khan University, Karachi.