This case documents the use of participation strategies by CALID and citizens to influence decision making in the fight against extortions in hospitals of the Tamale metropolis of Ghana.
Problems and Purpose
The purpose of this intervention was to expose the phenomenon of extortion of citizens or clients of the three major hospitals in the Tamale metropolis of Ghana in West Africa. It also sought to create an opportunity for citizens (right holders), hospital authorities (duty bearers), and other stakeholders in the health sector to work together to find solutions to the problem of extortions.
The issue of the extortion of citizens at health facilities in Ghana, and most especially the Tamale Metropolis, had been a topical issue in communities and the news. A baseline survey conducted by the Centre for Active Learning and Integrated Development (CALID) in 2018 observed that, clients of hospitals frequently complained of corruption in the form of unauthorized and illegal charges being handed down to them by health workers in health facilities in the Tamale Metropolis. According to the survey, this made accessing and paying for medical services unattainable for many poor people. Additionally, authorities took minimal actions to address this issue (CALID, 2018). Thus, broad participatory action was required to curb this extortionate behavior.
Background History and Context
Corruption has a long history (Nye, 1967) in Ghana and is fairly endemic in all government institutions. In the health sector, corruption can undermine service delivery, and has an especially detrimental impact on the poor. According to Mary Robinson, former UN High Commissioner for Human Rights and former president of Ireland, it is also a human rights problem: “Corruption literally violates human rights, as people are denied the care that their governments are obligated to provide.” (Global Corruption Report 2006, p. xiv).
Corruption in the form of extortions in the health sectors of African countries including Ghana has been an issue in the public space for years. According to a report by World Bank in 2010 called "Africa Development Indicators", quiet corruption in the health care sector is widespread in Africa. The report further explains that “quiet corruption is when public servants fail to deliver services or inputs that have been paid for by the government.” (2010, p.vii)
The common form of corruption in the Tamale Metropolis health sector is petty corruption which involves charging illegal fees for services without receipts or with falsified receipts, and without following the proper payment procedures of the hospital. According CALID’s survey in 2018, services and goods are sold to patients without receipts. Sixty-four percent (64%) of community-level respondents and 45.4% of patients respectively indicated that they have confronted this situation many times. As a result, poor citizens who travel from afar, after paying for high cost of transportation, are asked to pay more charges for drugs and services even though they may be covered under the National Health Insurance Scheme (CALID, 2018, p13).
Major reason for extortions included inadequate monitoring by hospital authorities, which made it difficult to identify and punish culprits. Additionally, hospitals lacked effective channels for citizens to report extortions. However, hospital authorities in an interview with CALID put the blame on clients (citizens) for their inability to report extortions to authorities. According to the Public Relations Officer of the Tamale Teaching Hospital in an interview with CALID, there had been previous attempts by hospital management to identify culprits of extortions through monitoring of staff but the result was poor and the practice still raged on. CALID saw the need for participation of citizens in decision-making of hospital management to help curb this problem (CALID, 2018).
In response to these issues, CALID’s citizens’ participation initiative utilized a bottom-up approach. Citizens were engaged using a citizen-driven social accountability tool known as the community scorecard (CSC) which enabled them assess service delivery and attitudes of staff of hospitals. CALID and citizens had used the community scorecard approach on another project to assess service delivery of Local Government officials in Northern Ghana. Additionally, an SMS Voices Platform, a mobile reporting mechanism, was used by CALID to enable citizens to report cases of extortions to hospital authorities. A platform was then created for citizens to interface with hospital authorities and other actors in the health sector in the Tamale metropolis to discuss and find solutions to the problem of extortions in Town Hall Meetings (CALID, 2018).
Organizing, Supporting, and Funding Entities
This participation initiative was co-designed and implemented by CALID and the League of Youth Association (LEYA). In fact, the main strategy of the project was citizen-centered approach, which put citizens at the center stage of the project. CALID had collaborated with LEYA since 2012 on other projects on improving youth participation in decision making in Northern Ghana. The experiences and results from the past project informed both organizations to collaborate and put together a proposal for support. LEYA’s role on the project was community-level mobilizing for action whilst CALID provided training support on community animation, monitoring, and the CSC. CALID also handled the overall management of the project.
The project, named Fighting Unapproved Charges in Health Services project was supported by STAR Ghana, a Non-Governmental Organization based in Ghana focused on active citizenship with international funding support from UKAID, DANIDA, and European Union. A total funding amount of GHC 200,000 was received by CALID and LEYA to undertake the project from March 2018 to March 2019.
Participant Recruitment and Selection
Participants of the Town Hall Meetings included citizens of 15 communities in the Tamale Metropolis especially women and minority groups like persons living with disabilities and minority tribes because they were the most affected by these issues of extortions. Also, selected senior staff and administrators of the main hospitals in the Tamale Metropolis participated because they are the bodies that preside over the hospitals and make decisions. The key staff of the Regional and Metropolitan Health Directorates also participated because they are government institutions with oversight responsibilities on all hospitals in the metropolis in-terms of policy implementation. The Directors for the regional/metro Health Insurance Scheme were also invited to provide education and clarifications to citizens’ concerns with regards to services and drugs covered under the health insurance scheme of Ghana.
With regards to criteria for inviting participants, purposive sampling technique was used to select duty bearers who were in position respond to the concerns of citizens and policy issues as well operational issues. Citizens who took part in the Community Score Card exercise were chosen as representatives of their communities to participate in the Town Hall Meetings to defend concerns raised in the exercise.
Methods and Tools Used
Multiple methods and participatory processes were employed in this intervention, namely: Community Score Card, SMS voices platform, radio and Town Hall Meetings. These tools were chosen to allow for the gathering of evidence of extortions in hospitals through the SMS Voices Platform and sharing to duty bearers for redress. In particular:
- The community scorecard provided an opportunity to gain a deeper understanding of citizens’ experiences of extortions and allowed them to assess the service delivery of hospitals in terms of some critical areas such as effectiveness of payment systems and attitudes of staff;
- The SMS Voices Platform provided by STAR Ghana facilitated information flow from citizens to duty bearers for redress. STAR Ghana also provided overall technical backstopping support for the project;
- The radio programmes produced by CALID and dubbed “Social Accountability Time” were greatly used by both LEYA and hospital authorities to educate citizens to insist on proper payment channels when they attend the hospitals, as well as reporting channels for extortions in the various public hospitals; and.
- The Town Hall Meetings provided an opportunity for citizens to interface with duty bearers on critical issues concerning extortions and other service delivery issues in the hospitals. In these meetings, citizens led by the League of Youth were given an opportunity to present the score card findings and concerns to duty bearers to respond to. The meetings also educated citizens on the proper payment channels in the hospitals as well as the need to demand for receipts for any payments made. Commitments were made by duty bearers at the end of the meetings concerning instituting measures to tackle extortions in hospitals.
What Went On: Process, Interaction, and Participation
CALID put in place systems for evidence gathering on extortions. Firstly, with the support from the IT Department of STAR Ghana, six members of the League of Youth Association were integrated onto the SMS Voice Platform as reporters. They were trained by STAR Ghana on how to report cases on the platform for duty bearers to respond to. Three Representatives of the three hospitals were also trained and integrated on to the platform as duty bearers on how to address respond to the issues coming from reporters on the platform.
Furthermore, the citizen-driven accountability assessment tool, the community score card was jointly used by CALID and the League Youth to gather evidence of extortions in the three main hospitals of the Tamale Metropolis and also gave an opportunity for citizens to assess performance of the hospitals in terms of quality of service provision.
CALID and the League of Youth also collaborated with various hospital authorities in the implementation of the ‘Social Accountability Time’ radio programme on Radio Tamale to sensitize citizens/clients of the main hospitals on the need to report cases of extortion and demand for proper payment channels in the hospitals. In every radio session, citizens were given an opportunity to phone in to make their submissions and ask questions for redress (CALID, 2022).
Overall, these methods provided citizens with valuable information to participate effectively and enriched discussions in the Town Hall Meetings. The Town Hall Meetings engaged and drew the attention of the hospital authorities to extortions and unapproved charges at the health facilities in the Tamale Metropolis. It also served as an interface between over 200 citizens, hospital authorities, and NHIA to discuss issues of extortions, negligent attitudes of health staff which were generated from the Community Score Card.
At the end of these deliberations, the outcome of these were discussed by CALID and LEYA on the radio to ensure information dissemination to the general public and possible replication from other districts or regions.
Citizens were engaged by project implementers through quarterly meetings to review and improve project planning and implementation. Additionally, CALID, LEYA, and citizens jointly held meetings with hospital management to discuss issues arising from project activities.
Influence, Outcomes, and Effects
Some significant results have been realized as a result of this citizens’ participation intervention:
First, citizens are now very aware of the various channels for reporting and are confidently reporting extortions and poor service delivery in the hospitals as a result of the sensitizations from hospitals and NHIA authorities on radio and Town Hall Meetings interventions of CALID and the League of Youth. One of the citizens who participated had this to say:
“The Town Hall Meeting gave us an opportunity to ask the hospital authorities critical questions and seek clarity about some payments made at the TTH we deem to be illegal fees. For instance, some payments we make at the theatre when we go for deliveries. We were sensitized by hospital authorities on the legal charges and appropriate payment points. It was really an enlightening experience.”- Alhassan Barkisu; Dabokpa community
Furthermore, citizen participation in the project helped to strengthen the accountability mechanisms in the hospitals. For instance, some of the hospitals were persuaded to put in place customer care units, which hitherto never existed to attend to concerns of clients when they visit the facility. According to Dr. Ken Osei Mensah of PRO Tamale Teaching Hospital:
“The CALID/ League of Youth project has enabled the hospital to identify and seal to some extent the loopholes of seepage of revenue in the hospital. This has been done with the help of reports from the youth on the SMS Voices Platform. As a result, the hospital revenue has gone up by 50%. […] The SMS Voices platform has enabled the youth (reporters) to send reports of unapproved fees charged at the hospitals to hospital authorities. During the quarter under review, a total of 6 reports have been sent. Some of the hospitals have taken drastic measures and sanctions have been placed on staff involved in the extortion of clients. Hospital authorities have collated the other issues and are still investigating for actions to be taken. Not only that they are going ahead to provide training for health workers on the customer care services."
Additionally, participation made citizens to understand their roles and the ways/strategies for holding duty bearers accountable to them. Above all, participation helped improve trust between citizens and hospital authorities to work together to improve health care delivery in public hospitals in the Tamale Metropolis (Mohammed, personal communication, 2022).
According to Sumani, the Executive Director of CALID, the Town Hall Meetings resulted in some of the hospitals putting in place customer care units taking inspiration from the reporting system of CALID’ intervention which hitherto never existed to attend to concerns of clients of the hospital.
It created a space for the hospital authorities to secure the trust of citizens and to restore confidence of citizens in accessing quality health service delivery by making commitments to put in place measures to deal with corrupt acts in the hospitals as well as ‘negligent’ attitudes of some staff of the hospitals.
The intervention also had unintended outcome: heightened interest of some other Media houses in the Tamale Metropolis on extortion and poor service delivery in the hospitals. Sagani Television Station in Tamale invited CALID and the League of Youth to speak on issues of extortion in the hospitals in the Tamale Metropolis and how the collaboration with citizens had been around these issues. This was after CALID’s informal collaboration with Joy TV on their investigative exposé christened “Robbing the sick” on extortion and corruption at the Tamale Teaching Hospital (Sumani, personal communication, 2022).
Analysis and Lessons Learned
What worked well in this intervention was the fact that CALID collaborated with citizens’ groups in project implementation of issues which directly affected them. It therefore made them passionate and they owned the process. The public participation approach eventually influenced duty bearers to not take the project for granted.
The intervention was challenged by a few issues, given that some citizens (victims of extortion) were still reluctant to report issues of extortion and to open up and report to authorities for redress for fear of victimization. However, they were re-assured that their identities would be anonymous on the reporting system and they would be protected.
Additionally, the reluctance on the part of hospital authorities in taking actions on issues of extortion and other service delivery issues in the hospitals really challenged the project. Citizens criticized and called out the duty bearers who were not taking actions reports on radio to make them change (Sumani, personal communication, 2022).
Another challenge had to do with the difficulty in getting duty bearers to come on radio as a result of bureaucratic issues in their organizations. Duty bearers were however persuaded to appreciate the benefits of coming on radio to clarify issues of extortion and provide education to citizens on proper payment channels in hospitals to avoid extortion (Mohammed, personal communication, 2022).
The successes of this initiative are transferable. The citizens who participated in this initiative stated that they were very satisfied with the strategies employed, especially its people-centered approach. They admitted that it was a very great opportunity to learn about the work of duty bearers and service providers. The duty bearers on the other hand were of the view that this approach, especially the radio and Town Hall Meeting strategies, allowed for the sensitization of citizens on proper payment channels and also allowed for duty bearers to get feedback from citizens to improve service delivery.
According to Sumani and Mohammed, CALID and the League of Youth have learnt some lessons from the implementation of our participation initiative:
- Firstly, the community score card exercise and the Town Hall Meetings helped to strengthen citizens-service provider relations and improved trust of duty bearer by citizens;
- Additionally, it was learnt that the intervention helps improve the behavior of health workers towards citizens and it consequently improved attendance to health facilities;
- Hospital authorities learnt that there was the need to formalize informal payment systems to block the leakages in order not to lose revenue for the facilities; and,
- Overall, it can be observed that, the participation strategies that were employed by CALID and the League of Youth has immense benefits for improving relationships between citizens and service providers.
CALID. (2018). Baseline Report on Perceptions about Unapproved Charges and other Malpractices in Health Facilities in the Tamale Metropolis. Tamale.
Glynn, P, Kobrin, SJ, Naim, M (1997) The globalization of corruption. In: Elliott, KA (ed.) Corruption and the Global Economy. Washington, DC: Institute for International Economics, 7–31.
Nye, J. S. 1967. Corruption and Political Development: A Cost-Beneﬁt Analysis', American Political Science Review, 61(2). 417-427.
Sumani Mohammed Awal; Executive Director of CALID (2022), Interview.
Inusah Mohammed; Deputy Secretary of LEYA (2022), Interview.
Transparency international (2006). Global Corruption Report. London N6 5AA. MI 48106, USA: Pluto Press. Ann Arbor.
World Bank (2010). Africa Development Indicators: Silent and lethal: How quiet corruption undermines Africa’s development efforts.