Untitled Document

Inverted State and Citizens' Roles in the Mozambican Health Sector

Jose Dias and Tassiana Tomé

This article aims to understand the inversion of roles between the state and citizens, by exploring its historical roots and current implications for processes of social accountability in Mozambique, particularly in the health sector. This is a practice-based reflection grounded in the evidence collected through the implementation of Community Scorecards in the health sector in 13 districts of Mozambique. The evidence has revealed a transfer of responsibilities from local governance institutions and service providers to the communities; diluting the frontiers between the state and citizens' duties and rights, resulting in the inversion of roles. This inversion results in the minimisation of the state's performance of its duties and accountability in the health sector to respond to local communities' needs, allegedly due to the lack of financial resources. It also leads to the overburdening of local communities, who assume the responsibility of meeting their own demands, risking participation fatigue.

Keywords: social accountability, health sector, rights demand, participation, community scorecard.

1 Background
In general, social accountability presupposes the existence of clearly defined relationships and roles, which enable the process of accountability from the state to its citizens. However, in the case of Mozambique there are some ambiguities regarding the mandate and competencies of the state. This results from changes in its role after independence amongst other political, economic, and cultural factors, which undermine the very essence and operationalisation of the concept of social accountability.

An analysis of the evidence collected through the implementation of Community Scorecards in the basic health sector in 13 districts of Mozambique has shown a transfer of responsibilities and tasks from local governance institutions and service providers to communities, and has revealed an inversion of the state and citizens' duties and rights.

This article is a practice-based reflection that seeks to explore the causes and implications of the transfer or inversion of the roles between the state and citizens, subverting the purpose of social accountability. On the one hand, it results in the minimisation of the state's performance of its duties and accountability in the health sector to respond to the local communities' needs and rights, allegedly due to lack of financial resources. On the other hand, it results in the overburden of local communities, who assume the responsibility of meeting their own demands, which they place on the health service providers at the local level, risking participation fatigue.

The remainder of this article is structured as follows. Section 2 focuses on a theoretical analysis of the inversion of the roles of state and citizen, and discusses citizen participation in the context of (neo) liberal democracy. Section 3 presents a historical perspective on the construction of the Mozambican post-independence state and its implications in the conceptualisation of citizenship. Section 4 discusses specifically community participation in the health sector in Mozambique, and analyses some of the normative instruments that regulate the participation. Section 5 offers a critical assessment of the Community Scorecard. Section 6 concludes with some elements for future reflections.

2 Inversion of the state and citizen roles within neoliberal democracy – a critical analysis
Social accountability is fundamental in ensuring a democratic and transparent governance able to respond to citizens' needs. The process of social accountability entails the capacity of citizens to monitor the performance of political representatives and service providers, in order to have their rights secured. It also involves a government and public servants capable of providing and responding to citizens' demands in order to realise their rights (Commins and Ebel 2010).

Within this approach, citizens are understood as 'direct beneficiaries' but also as 'monitors' of public services and government performance, which uses public funds to respond through their programmes and services to citizens' needs and proposals. In this context, the participation of the citizen emerges as central to a democratic governance, which is reflected in the growing creation of public spaces for civil society involvement in the discussion and decision-making related to public issues. These formal public spaces theoretically propose the sharing of power between citizens and public authorities as a means for deepening and broadening democracy. However, as discussed by Gaventa, participation in such public spaces 'has failed to deal with the hard politics of party building and mobilisation of demands (Houtzager 2003), thus enabling weaker forms of participation to be easily captured and co-opted by a neoliberal agenda' (2006: 17).

However, some experiences reveal that frequently spaces open to the participation of citizens and different sectors of civil society in the evaluation of public services and formulation of public policies end up being spaces used for the transfer of functions and responsibilities from the state to civil society. This transfer of tasks is related to the implementation and execution of the established plans of the local government, in such a way that civil society and citizens begin to provide services or perform responsibilities previously considered as duties of the state (Dagnino 2008).

Such transfer of responsibilities and inversion of the roles of the state and citizens was identified in the experience of social accountability at the local level in the health sector. It was facilitated by district platforms of community-based organisations that are partners of the Centre for Learning and Capacity Building for Civil Society (CESC), Maputo, Mozambique.

A byproduct of this process of local social accountability in the health sector, which also involves planning and joint action between public providers and citizens, has been the growing responsibility of local communities to contribute to the construction and improvement of health infrastructures. As a result, the social functions of the state were reduced with regard to this aspect.

In a recent study, Kleibl, Ilal and Munck (2014) question how Mozambicans conceptualise 'civil society'. One of the interviewees, a worker at a local non-governmental organisation (NGO), stressed that 'it is very important to have clear lines between the state, the market and civil society' (ibid.: 14). At the same time, he stated that civil society organisations (CSOs) should complement the state's work in cases where it is weak and unable to fulfil its role. In this light, it is possible to note that while there is a need for clear boundaries, there is a sense amongst different CSO actors that civil society has a moral responsibility or obligation to complement or fill the gaps of the state.

According to Dagnino (2008), this transfer of social responsibilities and the 'exploitation' of citizens' participation in ways that lead to the handing over of accountability from public institutions and services to its citizens, is the result of what she calls 'perverse confluence'. It is the confluence between two distinct political and cultural movements of democratisation, which use the same references and lexicon but with different underlying understandings, such as 'citizenship' and 'participation', and make use of similar operational mechanisms such as joint participatory planning.

On the one hand, there is the political and cultural project of neoliberal democratisation. It is based on a minimalist state with fewer social responsibilities and a smaller role in realising citizens' rights, as it relies on facilitating the privatisation of different public services. This project is also based on an active but neutral and technocratic civil society, which also assumes the role of a public servant (Tar 2009; Shivji 2011).

On the other hand, there is a political project of democratisation emerging from endogenous social movements and initiatives seeking an effective sharing of power between state and civil society. Such co‑sharing of power involves deepening the capacity for citizens' greater deliberation in public spaces, and the construction of citizenship as the exercise of redefining and expansion of rights. This is not only in the formal politico-juridical sense, but also in the sense of a more egalitarian sociability between state agents and citizens in the resolution of structural issues, and in the designing of the development agenda and its underlying political and economic paradigms.

Both projects require an 'active and engaged' civil society and 'participatory citizenship', but there are fundamental distinctions in the aims and meanings of this common terminology (Dagnino 2008).

For instance, the exercise of social accountability, civic engagement, and power-sharing at the local level is marked by joint planning and resolution of local problems, bringing together the state and citizens. However, in the neoliberal context of a minimalist state, this exercise tends to involve rather immediate, individualistic, and 'managerial' resolutions of local problems that end up becoming the responsibility of the most vulnerable and low-income citizens, who already have a restricted access to quality services. For Dagnino (2008), this mere technical management of the precariousness of social services and poverty results in depoliticised micro-interventions, which do not take into account deeper structural power asymmetries, such as class relations, and also remove from the arena of participation notions of justice and social equality as struggles towards correcting such power imbalances.

In this sense, the democratising political potential of this exercise of participatory monitoring and joint planning is reduced, since a greater balance and reciprocity of power between state and citizens is not achieved (Commins and Ebel 2010). Citizens' efforts to demand the realisation of their rights is replaced by efforts to fill the gaps in public services. Most of the time, these efforts in resolving local problems are realised in ways that are disconnected from the macroeconomic and structural causes underlying the deficiencies of the public services and state's performance. This situation can potentially generate fatigue amongst citizens, who get a sense of having their participation 'exploited' to carry out already established agendas, and can exempt public agents from their role of serving and guaranteeing the materialisation of community rights. The disconnect between local effort and more central and structural resolution of the problems faced by citizens reveals the need for decentralisation policies that allow greater accountability to local authorities, and greater local autonomy shared equally by the state and the citizen.

It is also relevant to propose an analysis of class and power to better grasp how participation and citizenship have been performed. This illustrates precisely how the most economically disadvantaged groups are the ones most overburdened, and the ones who undertake the tasks the local services and government are unable to realise. With regard to power analysis, Osaghae (2003) discusses the existence of two publics or social groups in the context of citizenship in Africa: a civic public that participates in local formal spaces such as consultative councils, and a primordial public residing within the context of family and community life and solidarity networks. Such analyses are important to understand the different hierarchies and inequities that shape the ways civic participation is happening within the public space.

As argued by Dagnino (2008), it is necessary to understand citizenship as the search for greater equality, not only in relation to the state, but at the very heart of society, and thus it is equally fundamental to understand the hierarchies within the public space as well as within civil society.

In this light, it is vital that the premises of collaboration and complementarity between state and citizen also privilege a space for contestation and antagonism. It is in this space that citizens can become shapers and makers. They can continuously propose redefinitions of the roles of the state and civil society in order to respond to the visions and proposals of new approaches towards a more egalitarian and just public responsibility and accountability (Cornwall and Gaventa 2000). This resonates with Gaventa's argument that 'democracy-building is an ongoing process of struggle and contestation rather than the adoption of a standard institutional design' (2006: 3).

In this sense, in order to guarantee the democratic potential of social accountability frameworks within local services, it is necessary to re-politicise the processes of citizen participation. In other words, it is necessary to consider citizens not only as beneficiaries of public services with already defined rights, but as formulators of these same rights, and agents in the definition of governance models and new social contracts (Dagnino 2008).

Similarly, Kleibl et al. (2015) put forward the idea that to overcome this 'crisis' in civic engagement, in Mozambique, it is crucial to go beyond purely technical processes of citizen participation, and to take into account the historical and current imbalances of local political and economic powers. In this sense, Section 3 presents a historical analysis of the processes of construction and redefinition of the state in Mozambique, including the historical roots of inverted accountability and its implications for citizen participation.

3 Building the post-independence state – to what extent has this context been building an active citizenship?
During the colonial period, Mozambique's economic structure was characterised by two main functions: (i) to maximise the extraction of resources, through production methods based in the exploitation of massive labour work; and (ii) mobilising foreign economic resources. Regarding the exploitation of labour work, in particular, the colonial state used slavery methods, including forced labour, forced crop cultivation, high taxes, and low wages, in order to ensure the raising of revenues for the state (Maloa 2016).

The rationale used by the colonial state was to consolidate the profit into fewer hands and promote conditions that favoured capital accumulation by Portugal and the Portuguese over all others. In such an environment, citizenship was a condition granted by the colonial state to certain populations, namely, the Europeans and the converted naturals – the 'assimilados'. On the other hand, the colonial state, through the regulation of indigenous labour, and discriminating against African tradition, assumed that its competence lay in taking responsibility for safeguarding the life of the indigenous people, who for 'civilisational' reasons were not in a position to take responsibility for themselves (Macamo 2014).

After gaining independence in 1975, the political relationship between the state and its citizens did not change significantly (Macamo 2014; Paredes 2014). In fact, the attempt to create citizens that were aligned with the state-party opened up space for the reconceptualisation of colonial practices in a new post-colonial socialist branding. One of the typical experiences that illustrates this is the so-called 'Operação Produção', which was used in the policy of building the 'new' Mozambican citizen. In existence since the early 1980s, this was an organisation of a popular re-education project in big rural farming fields, mainly located in the north of the country. These farms served as true laboratories for the political reconversion of any individuals who expressed political dissent. These individuals cultivated the farms, built their homes, and by the end of the day would participate in the Marxist–Leninism political courses (Paredes 2014).

On the other hand, based in the territorial control of the liberated zones, the liberating party controlled agricultural production, creating an economy based on the trade of goods produced by farmers such as peanuts, maize, and cashew, and goods provided by the military which the farmers could not cultivate such as salt, sugar, and clothes. Despite the early incentives the farmers had for trading, they later became convinced that the terms of trade were unfair, and they also became aware that the liberating party was primarily serving its own interests (Bragança et al. 1983).

In practice, the post-colonial state had the prerogative to direct the dynamics of the political, economic, and social spheres, and eliminated any form of social pluralism (Lalá and Ostheimer 2003). Such logic contributed to the conversion of the liberating party into a hegemonic political institution, in relation to civil society and to the institutional spheres in which the society was founded: namely, the market, the state, and the family (Francisco 2011).

The current phase began in 1990, having as the key feature the approval of the new democratic and multiparty Constitution that grants new rights and freedoms, including the right to information, freedom of expression, and freedom of association. In general, this phase seeks to consolidate the democratic model and the liberal economy, building on, amongst other aspects, the gradual decentralisation and deconcentration of the state administration and the promotion of citizen participation (CIRESP 2001).

In the early 1990s, this environment enabled the creation of religious and professional organisations that sought to contribute to emergency and relief actions during the civil war, contributing to the provision of medicines and the building of basic social infrastructures, particularly in the health and education sectors. Later on, with the approval of the new Law of Associations, the country witnessed the development of interventions related to civic education, human rights, elections, accountability, and participation in a plural society (Lalá and Ostheimer 2003).

The quest for the promotion of citizen participation in governance, in particular, has also been witnessed in the progressive formulation of a set of general and sectoral public administration legislation aimed at creating a vibrant citizenship. It is within this framework that one can find general instruments, such as the law and the basic decree of organisation and functioning of the public administration (Law 7/2012 and Decree 30/2001), the law of local state bodies (Law 8/2003), as well as the Charter of the patient's rights and duties, in the health sector, which provide a set of mechanisms that guide the individual or collective participation of citizens for influencing public decision makers on issues that affect them.

Despite these normative efforts made for deepening democracy, there are key factors posing challenges for achieving the outcomes of citizen participation and engagement. For instance, although access to information is a precondition for citizen participation in service provision and local governance, there is insufficient culture of accountability in most public institutions, especially at local level. In such an environment, the provision of information about services for the citizen is not prioritised.

Power relations are the other key factor hindering the achievement of the outcomes of participation. At the local level, power relations are very unfavourable towards citizens, particularly vulnerable groups such as poor women, the elderly, and children, and social structures are dominated by the local elite, mostly related to the governing political party (CEP 2013).

The other barriers to the exercise of citizenship have to do with inequalities of gender and wealth, poverty, illiteracy, and lack of access to the formal structures of the state. Even with the opening of new spaces of interaction between the government and the citizens, such as development observatories and consultative councils, such spaces need clear arrangements for citizens' recommendations to be taken into account in government policymaking (AfriMAP and OSISA 2009; Forquilha and Orre 2011).

4 Functional issues in the health sector: who does what, when?
Apart from little openness, and weak political inclusion, the state is affected by the lack of clarity in the separation of roles between the public sector and the citizen. In our view, the notion that the provision of services is not an exclusive role of the state, but a shared responsibility, which is also reflected in health sector policies, is the root of this ambiguity.

The main issue here is the lack of clarity in the delimitation of the criteria from where the role of the state and the citizen begins and ends. This is confirmed in different health sector policies, of national and international origin, where it is possible to find diversified and even disjointed concepts regarding the role to be played by the citizen participating in the solution of health problems:

  • In one of its seven guiding principles, the Health Sector Strategic Plan (2014–19) reveals the intention of the health sector to establish a partnership with civil society and NGOs to promote advocacy and service provision (MISAU 2013). The underlying notion of this policy is the sectoral partnership expected with the intermediary institutions and not with the citizen.
  • As a community health agent (CHA), the citizen plays the role of service provider, increasing the coverage of basic health services for the community. This concept is reflected in the community involvement strategy, which defines CHAs as 'all individuals, chosen in the community, who are trained by the health sector, or NGOs and religious institutions, to carry out promotional, preventive and/or curative activities at the level of communities. Within the CHAs group are the elementary polyvalent agents (APE), traditional midwives and activists' (MISAU 2014: 1). If we accept that the elementary APEs assume the role of a service provider, then we should also accept the inherent double accountability relations in which they are involved: they are subordinated to health institutions in performing their function; for example, regarding the request of medicines and accountability for their use. But they are also accountable to local communities regarding their performance.
  • The citizen appears as co-manager and decision maker of the health facility, as a member of the co-management committee, and a community agent when integrated into the health committee. The former committee is a multidisciplinary body made up of workers, health managers, and community members working together to plan, execute, and monitor activities, including analysis and decision-making on all aspects of the health facility (MISAU 2012a). The latter committee is a socio-community structure composed of members chosen or elected by the community for 'its representation' at all times and to make decisions on health (MISAU 2012b: 9).

However, by virtue of its inherent functions, in practice, by possessing key information and knowledge, the health workers and managers integrated into the co-management committee have greater decision-making power than other members. Regarding the health committee, although it is established that it should not be subordinated to health institutions, it is expected that political parties will participate in this committee, risking the co-optation of the opinion of other actors, and minimising the freedom of expression of the citizens integrated therein.

  • The Charter of the Rights and Duties of the patient can be considered an instrument of empowerment that seeks to instil the sense of self-agency of the citizen as a health service user. The Charter can be defined as a guiding instrument that establishes the standards to be demanded and respected by the citizen and health personnel, respectively, in the provision of services (MISAU 2011). However, despite its aim of empowering the citizen, the lack of knowledge and experience of exercising the rights foreseen by the user and the provision of rights locally is not feasible, because of the lack of resources which restrain the degree of its implementation.

Overall, it is noted that in addition to the lack of conceptual harmonisation of the role of the citizen in the health sector policies listed above, the mechanisms of participation therein established are affected by operational dynamism that impedes the performance of a substantial citizenship. This results in the demand for accountability from citizens to the service providers and political leaders.

There is a compelling empirical example that shows one of the effects of lack of conceptual harmonisation on paper in everyday practice. During the monitoring visits conducted by CESC in Montepuez District in 2016, members of the co-management committee expressed that because of the role they played as co-managers and decision makers of the health facilities, they felt it would be impossible to individually demand the implementation of the Charter of the Rights and Duties of the patient when accessing these health facilities as users. The point being made here is that they did not feel like community members and expected this role to be played by others – referring to those whom they mobilised. This case shows clearly that these members abdicated from some of their rights, particularly regarding active citizenship, in order to assume other rights.

5 The Community Scorecard: an opportunity for the exercise of an active citizenship?
The Community Scorecard can be defined as a participatory tool that (i) is conducted at micro/local level and uses the community as the unit of analysis; (ii) generates information through focus group interactions and enables maximum participation of the local community; (iii) provides immediate feedback to service providers and emphasises immediate response and joint decision-making; and (iv) allows for mutual dialogue between users and providers, and can be followed by joint monitoring (CARE Malawi 2013).

Like other social accountability tools, the Community Scorecard has a high potential to promote the exercise of active citizenship. In this vein, Malena, Forster and Singh (2004) argue that social accountability mechanisms are top down, and contrary to the elections which are blunt, accountability mechanisms allow citizens to express their preferences on specific issues, participate in the decision-making process, and hold public officials accountable for particular decisions and behaviour.

Table 1

However, the experience of implementation of the Community Scorecard by CESC partners shows that there are a considerable number of cases where, after scoring in relation to their satisfaction regarding health service delivery, community members assume the responsibility for providing resources, building infrastructure, and/or providing services during the building of infrastructure, in partnership, or even replacing the government.

Table 1, extracted from CESC partners' Community Scorecard reports from 2014 and 2015, shows that out of a total of 64 infrastructure construction cases, such as nursing homes, medical staff residences, and opening of hospital landfills, the government assumed full responsibility for the performance of this function in only 66 per cent of cases.

In the remaining 34 per cent of cases, the local government counted on community labour, with the community assuming full responsibility in building such infrastructure. The community also shared responsibility with the local government in building such health infrastructure in 6 per cent of cases.

There are also situations of change of responsibility between the government and communities over time in at least two districts. While in 2014 the community assumed more responsibility in the building of infrastructure in Mandlhakazi District, in 2015 this picture changed as the government took responsibility for more cases than the local community. Similarly, in 2014 in Quissanga District, the government assumed more responsibility than the community, a situation that changed in 2015 when the community took over more cases than the government.

It is worth noting that in 2015 Mandlhakazi District appears with a high number of cases of community involvement in the process of building infrastructure, tending to be almost in balance with the government's responsibilities in this regard.

The key lesson to be drawn from the data in Table 1 is that the nature of contradictory accountability in current relations established between state and citizen can significantly influence the way in which social accountability is implemented.

In other words, and in light of the discussion in Section 4, we can argue that although it constitutes an opportunity for the exercise of freedom of expression and accountability, the representations, resulting from the past experience of playing passive citizenship roles, and the lack of experience of exercising a substantial permanent citizenship, can subvert the sense of accountability that one intends to construct within the social accountability approach.

It is worth noting that although the type of infrastructure built by communities does not necessarily follow the technical standard established for public infrastructure, and even though the efforts and costs mobilised in the infrastructure built by the state differs from that of communities, community infrastructure is locally accepted and used by medical staff, because it closes the gap of lack of conventional infrastructure, in an environment of scarcity of resources.

In practice, this kind of scenario has often resulted in the overburden of local communities, who assume the responsibility of meeting their own demands, reproducing historical patterns of unequal labour demands, and risking a sense of participation fatigue.

6 Concluding remarks
Knowledge of prior relationships and construction of roles of the state and the citizen is a key element for CSOs promoting the social accountability approach. Knowledge is necessary in order to define the entry points to promote the transformation of roles and values in order to establish vertical relationships between the parties. Otherwise, they risk not achieving the desired results.

The Community Scorecard tool operates in a complex context, of existence of mechanisms of citizen participation promoted by the state that instils inverted accountability relations. Thus, there is a need for a holistic effort to reconceptualise the role played by citizens and public institutions, as a requirement for creating an enabling environment in which a sense of accountability can flourish. However, given the historical background that we have discussed, it must be acknowledged that this may only be achievable in the long run.

The studies that may bring further data to deepen the discussion raised here would include the following subjects:

  • Citizens' belief in public institutions and their capacity to solve their priority demands;
  • Perception of the community regarding participation mechanisms, including those promoted by the state and civil society; and
  • Knowledge of rights and duties of citizenship and the willingness for long-term civic and political engagement.

The central issue, regarding the transfer of responsibilities from the state to the citizen, is how to alter the maintenance of asymmetrical power relations between these agents, and the non-resolution of structural questions relating to social inequality. These asymmetrical power relations are camouflaged in the processes of social accountability through planning and joint resolution mechanisms, in which participation is vulnerable to instrumentalisation, thus reducing the democratic possibility of greater transparency and the co-sharing of decision-making power.

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© 2018 The Authors. IDS Bulletin © Institute of Development Studies | DOI: 10.19088/1968-2018.134

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This article is part of IDS Bulletin Vol. 49 No. 2 March 2018: 'Accountability for Health Equity: Galvanising a Movement for Universal Health Coverage'; the Introduction is also recommended reading.