There’s a basic premise held by many in the citizen agency space. Empower citizens with the right information and the right tools and they will change the governance environment for better. This premise is encoded in just about any program / initiative focused on improving service delivery in Africa.

The premise is broken.

The late Morris Moses Kiromo was a 29-year-old Kenyan at the prime of his life when he unexpectedly fell ill in mid-2009. What began as a flu infection rapidly turned serious when the young man fell into a coma and was hospitalized at a major referral hospital in Nairobi. Morris remained in this state for several weeks in what turned out to be one of the most trying times for his family. They were especially devastated by the deplorable health care provided to Morris and many others at the publicly funded hospital. Sadly, Morris never woke up from the coma and he passed away in the early hours of 6th August 2009.

www.morrismosesfoundation.org

Mothers queuing at Sindo District Hospital
Mothers queuing for treatment at Sindo District Hospital in Nyanza, Kenya.

Just a few months earlier, Alice Mwongera, Morris’ sister had lost her husband Isaac at the same hospital in Nairobi following what she believes were negligent delays in providing him with the right treatment. She had had enough and together with friends and well-wishers she set up the Morris Moses Foundation to advocate for patient rights. Like many other patients and their families before her, she knew her rights and that the hospital was violating them but she had no success in getting the administration to pay heed to the plight of her husband or her brother. Her feedback produced no results.

Alice’s story is not unusual especially at the hospital where her family members died. The press continues to highlight cases such as this one that demonstrate the dire need for improved quality of service in many of Kenya’s public hospitals. Citizens know their rights and they complain but institutionalized change seems to still be a long way off.

The harsh reality in emerging democracies with nascent institutions, and probably in established mature ones as well, is that citizens have no real voice in the face of large organizations with deeply entrenched vested interests. These interests don’t have to be the nefarious financial kind either. The interests could be as mundane as the proclivity for staff in one government department to take an early and extended lunch break, because it suits them. Educating citizens about their rights where service provision in regard to the civil service is concerned is necessary but in isolation akin to carrying water in a basket. Gains made by one individual never go far enough and almost never result in institutionalized change in the service organization.

100 single citizen voices are very much like a tree falling in the forest. With no structured mechanisms to hear them, no one’s quite sure if they made a sound. It is therefore necessary to make a small adjustment to the underlying premise in order to design interventions with better efficacy. By all means empower citizens with the information they need but in addition link and equip intermediaries that have the phase shifting power to stimulate action. Once 100 single citizen voices are aggregated behind one or two credible ‘receptacle’ platforms citizens trust and that command respect from service providers, bureaucratic mountains will move to affect policy and service delivery in government or the private sector in sustainable ways.

These responsive ‘receptacles’ that have horizontal respect with other actors in their space and inspire trust with citizens are, in my view, the element that has been missing. As we work to give citizens a voice by designing innovative new platforms, as low-tech or hi-tech as they may be, we should remain aware that these, for the most part, won’t achieve their objectives in isolation. Collaboration must be leveraged for progress to be realized. The outcomes from this collaboration are maximized when the right partners are brought together through linkages fueled by the institutional self interests of these stakeholders. And this is where the 5 principles come in.

  1. Design for aggregation. Create not just a platform to collect views but the partnerships with consumer lobby groups, media and industry regulators necessary to exert sustained pressure on service providers to resolutely deal with the feedback provided to them.
  2. Design for collaboration. Human beings are social creatures. Allowing people to comment, support and share their stories allows those vested in it to participate in the push for change. Collaboration doesn’t have to be via online platforms either, it can be through community interest groups or faith-based organizations which already bring citizens together regularly at churches, temples and mosques.
  3. Design for transparency. Aggregated stories of people’s experiences and the complaints being forwarded to industry regulators is important as it provides late adopters with the social proof they need to validate their use of the platform. It is how citizens know their feedback will result in action. It also keeps unscrupulous individuals from hiding the true status of public complaints related to service delivery.
  4. Design for amplification. Make room for feedback presented to be seen beyond the platform through innovative use of social media but also through partnerships with infomediaries who can tell the story on platforms with wide and deep reach whether offline or online.
  5. Design for people. The linkages between the citizens and these organizations need to be as low friction and low cost as possible, leveraging whatever ubiquitous channels lend themselves to the use cases or the contexts. Many well-intentioned programs fail because they don’t take into account how people behave in the real world. For instance, an app that helps citizens locate the nearest hospital may be pointless as anecdotal evidence suggests residents already know where health care services are located in their community.

In a recent report by the World Bank on citizen participation and how it has worked, the authors categorize participatory environments into two main types; organic and induced. Organic participation refers to civic-driven initiatives usually centered around or driven by a charismatic individual or civil society organization that drives the vision and mobilizes citizens to act. Organic participation tends to be adversarial to the state and can be effective in getting governments to make policy changes. Induced participation refers to state driven programs that are policy based and implemented via bureaucracies. To achieve success, the bureaucracies should be robust, transparent and collaborative while focusing on citizen needs. They represent the best chance of achieving sustainable and scalable change. Consumer lobby groups such as Morris Moses Foundation and civil society organizations collect feedback from citizens and their work locally may result in change but scale requires state involvement.

One of the report’s empirical findings is that “local participation appears to increase rather than diminish the need for functional and strong institutions at the center.” It’s these ‘strong institutions’ that serve as ‘receptacles’, amplifiers and enforcers for citizen feedback with the enforcement role being played by the state. It shouldn’t be about choosing one approach to participation versus another. There are situations that lend themselves very well to adversarial engagement with the state while there are those in which a more collaborative state-driven approach would result in better outcomes. Alice and her foundation represents an archetype found in many parts of the developing world. Involving them in efforts to improve citizen engagement and creating an environment that fosters partnerships among stakeholders provides the foundation for their outcomes to scale up and result in change across the national healthcare system, not just a single hospital. Understanding what works for citizens and designing the right interactions with the right partners may be the solution to the nagging question many have asked, “Why don’t citizens participate more despite our best efforts?

The idea of an informed citizenry is important. The idea of an activated citizenry is a better ideal to reach for.

 

Image source: Flickr user DFID