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Submitted by Edouard on Tue, 09/16/2008 - 11:51.
I was in Yemen three weeks ago, in part to lay the groundwork for a national diagnostics survey of governance and anticorruption in the health sector. Its focus was to be on bribery and informal payments. Two years ago, a chapter in Transparency International’s Global Corruption Report 2006, “Informal Payments Take a Toll on Moroccan Patients” had identified the payment of bribes as a major challenge confronting patients in Morocco and in the MENA region in general. What about Yemen, where the recently established Supreme National Authority to Combat Corruption had asked the World Bank to conduct such a survey?
A longer, larger Bank mission to Yemen was scheduled for the month of October, which would typically include field visits to primary healthcare centers in the company of Yemeni government officials. My colleagues and I were also planning a number of focus groups across the country with the participation of medical and administrative staff from primary healthcare centers, and were hoping that the focus groups discussions would help us understand the incidence of bribes and informal payments in the primary healthcare sector.
Still, my plane wasn't taking off until late that night, and I thought that the anonymity of an unannounced and low-key visit would allow me to get a first taste of how a typical healthcare center operated, and if possible, to ask a few indiscrete questions. So I took a bus ride to one of the outer suburbs of San'aa, and stopped at what looked like a small village on the verge on being absorbed by the mushrooming Yemeni capital.
I walked to the first primary healthcare center, a dilapidated, decrepit house. It looked closed. A few knocks and shouts later, and I was convinced it was closed. How come? It's only 11 a.m. on a Wednesday. "Where's the healthcare officer? I asked the boy at the nearby car-repair shop. "Driving his cab" was the answer. "How can I reach him?"
I dialed the cell phone number the boy gave me, someone answered, I asked to be picked up and driven to a nearby village. This would give plenty of time to probe him about the healthcare center. Once in the car half an hour later, the conversation with Salem (my thirtysome cabdriver and absentee healthcareofficer) quickly turned to how he could juggle two jobs at the same time. I said nothing about the general nature of my work or about the task that brought me to Yemen, so as not to arouse his suspicions.
"My salary is 25,000 Rials (about 125 USD), my rent in San'aa is 20,000 Rials, and I have three children", said Salem. "My second job as a cab driver helps me take care of my children, bu it's still not enough to make both ends meet."
"But why not a part time job outside government working hours?" Wasn't he aware that his regular absences from the healthcare center - rather his absenteism, but the use of that technical word, 'taghayyub' in Arabic, would have given me away - were putting the people in his village at risk?
"I have a cell phone, people call me when they are sick, and I head back to the healthcare center. Besides, if it is urgent or serious, people have to go to the hospital in San'aa anyway, all I can do for them is to take them there" said Salem with a smile, and a wink that made me guess that he also charged sick patients for the ride.
He also added that few customers used cabs in the afternoons, since many were in homes chewing qat - the local drug that is plaguing the Yemeni society, the economy, and exhausting the water resources - so he started driving his cab in the mornings as well, effectively leaving the healthcare center unattended.
I also learned that most of Salem's aquaintances who had a government job did what he did: they were either self-employed or had a second job in the private sector, and collected a salary from the government at the end of each month. They would rarely come to office, if at all. Many were ghost workers, unlike Salem, who claimed he was always available to treat sick patients, by leaving his cell phone number with the shopkeepers next to the healthcare center.
Being caught was not something he or his friends worried about, as government inspectors could be easily convinced to turn a blind eye and surprise visits were practically non-existent. NGO and donors' visits were announced in advance _ as would probably be the case for own field visits next October.
The conversation continued along the same lines until we reached the next village. I paid Salem, thanked him and walked away, feeling rather uneasy. The phone hadn't rung once in more than an hour.
What's one to make of all this? Life in Yemen is exceedingly expensive, average salaries in the public sector are low, so people work two jobs, sometimes three. The job they end up neglecting is the government job, where the risk associated with this behavior is near zero, because of lack of oversight and accountability. The risk of tarnishing one's reputation is also insignificant, because everyone they know acts in the same way. That's what economists call distorted incentives.
Meanwhile, absenteeism has consequences on the lives of other people, literally in the case of Salem the healthcare-officer-turned-cabdriver. Yemen has a high infant mortality rate for children under the age of five, 78.8 deaths per thousand children, according to the UNICEF. I doubt many Yemenis know this, and if they did, they'd blame it on corrupt senior officials and politicians, like Salem did. Corruption is always elsewhere, usually one pay grade above you. When it's about you, it's called survival.
All of a sudden it felt silly to ask patients how much they were paying the likes of Salem to increase their level of sickness so as to get a quicker appointment with a doctor in San'aa. Salem was nowhere to be bribed in the first place. No exchange of money was taking place, for sure, but no service was being delivered either. What I was witnessing was not an instance of poor service delivery, but one of no service delivery at all. Meanwhile, sick people were left to fend for their own and the government was paying salaries to people who never came to work.
Of course, Salem's story is what we here call "anecdotic evidence". One story - even a dozen stories - cannot be used to derive policy recommendations. It will only serve to illustrate a phenomenom the magnitude and incidence of which is otherwise measured in nationwide surveys and empirical analysis (it does makes a good story for a blog entry though).
As someone involved in one such survey, I felt the need to change the focus of my healthcare users' questionnaire. Questions like: "Over the past year, how many times did you come to the primary healthcare center during working hours and found it closed?" could be added to the users' questionnaire and others like "During the past year, how many times did inspectors conduct surprise visits to the healthcare center?” could be asked to focus groups involving heathcare center staff.
Answers to these questions and others will not get Salem back to his healthcare center in the short term, but if significant, they will alert well-meaning health officials of the need to address the incentives of primary healthcare staff, and increase oversight. Raise the cost of receiving a government salary while continuing to drive a cab all day. Multiply unannounced visits. Identify and sanction offenders, double-dippers and ghost workers. And make it more attractive to work in a healthcare center than to drive a cab. Reward those who come to work every day by raising their salaries, by promoting them quicker, or by mapping them to locations closer to loved ones.
Stay tuned to the users' survey questionnaire, and to upcoming survey results. I will share these with you once they are finalized and reviewed by Bank colleagues and others in the Yemeni government and civil society. I will be glad to get your feedback.
Hai
Submitted by Hai (not verified) on Wed, 04/01/2009 - 00:41.
I recently came across your blog and have been reading along. I thought I would leave my first comment. I don't know what to say except that I have enjoyed reading. Nice blog. I will keep visiting this blog very often.
Sarah
Accountability
That was a very interesting piece, not so much because of the subject, but rather because of the coverage of aspects of governance that typically get left out of the impenetratable reports that get written on such issues. The messages I take away from the story are: 1) once we understand the existing system incentives (which given cultural pecularities is itself a formidable task), what do we do about it ? 2) The more information (surveys, statistics) the better, of course assuming there is buy in from the government
One idea to promote 2) is as follows - use Web 3.0 tools to construct rating sites akin to citizen report cards. One reason citizen report cards have not worked that well, I think, is that the instruments used have not been democratized. By this I mean to say they have been mostly manual, and therefore not accesible to everyone. If we were to pick one country, and one sub-sector and pilot a rating site using social networking tools I think this idea would have a good chance of being proven right. For instance a Yelp-like site for a collection of districts in Mexico. Check out http://yelp.com to see how yelp works or http://unigo.com or this article about how democratic bottom-up unigo became a hit: http://www.nytimes.com/2008/09/21/magazine/21unigo-t.html?pagewanted=2&em