Social Accountability Monitoring in the health sector in Ileje: The promises and challenges

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In May 2010, Policy Forum (PF) and MIICO[1] (Mbozi, Ileje and Isangati Consortium) entered into a partnership to implement Social Accountability Monitoring (SAM) in Mbeya region. Specifically, MIICO stakeholders in Ileje selected the health sector in Ileje District Council to begin their SAM intervention in the region. The intervention began with PF training MIICO staff followed by the introduction of SAM to Ileje District officials. The Ileje District commissioner, Acting District Executive Director, other district officials (Land, Natural resource, Health, Community Development, Agriculture and Cooperative Departments) were all introduced to the concept and agreed to collaborate with the MIICO team and other civic actors from Faith-based organizations and CBOs operating in Ileje District in the implementation of SAM.

The SAM exercise in Ileje noted a critical shortage of staff as one of the major health challenges in the district. The monitoring team questioned why, if there was a budget allocation for these posts, they could not be filled during the financial year. It was even speculated that perhaps the budget allocation was inadequate.  The response obtained from the Council officials was that the process for recruitment for health posts is long, involves several steps including the President's Office - Public Service Management and the Ministry of Health and Social Welfare, and the mandates for each stage of the process are unclear due to conflicting messages from current legislation and regulations. It was stated that even the number of posts in the staff establishment did not meet the staff requirements that they had in the health sector.

Two dispensaries had been built, one in Chabu Village and the other in Shinji Village and completed since 2009 but were yet to begin operations. Villagers informed the team that there was no dispensary nearby and they had to travel across the border to Malawi to attend medical services. This required crossing the Songwe River, which was uncomfortable and dangerous, particularly for expectant mothers. Children were also affected in that their  parents spent long times attending  health services far from home. Furthermore, the dispensary in Chabu had several difficulties, including huge termites despite requirement in the Bill of Quantities for construction of dispensaries using only treated timber.

Constant follow-up by the monitoring team began to yield results. During a visit on January 31st 2012 at both Chabu and Shinji dispensaries, the team was told that personnel were already recruited. Therefore, pending the completion of staff housing and registration, the dispensary would be able to begin operating immediately. As of July 2012, Chabu dispensary has been operational with two staff having now begun work and a third one soon to join. Personnel for Shinji dispensary are still awaiting the completion of staff housing.

To this end, SDC who fund the Policy Forum SAM initiative in Tanzania, joined the implementers to travel to Ileje with MIICO to see the impact and challenges of the intervention.  The visit, on September 3rd and 4th, 2013 was also aimed at allowing SDC staff to understand the work of her partners better. This report is a brief account of the visit and highlights some of the key issues that came across during discussions in Mbeya.

MIICO: The Partner on the ground

On September 3rd 2013, MIICO invited the visiting team to their offices in Mbeya and provided them with an overview of the organisation. The consortium currently implements 4 projects of which two are on SAM in the agriculture sector in Ludewa (supported by SDC), Makete, in Njombe region and Mbarali, Momba and Ileje  in Mbeya region (supported by FCS).[1] The others are a project aimed at advocacy for smallholder farmers to secure access to agricultural productive land in Sumbawanga and Mbarali Districts, supported by DKA/Welthaus – Austria) and a scheme to develop markets and entrepreneurship funded by Cordaid of the Netherlands in Mbeya Region.

MIICO’s engagement in SAM only began when the organisation was selected to partner with PF in SAM during the latter’s AGM held in April 2010 and thereafter chose Ileje district as their first area. As part of spill-over success, the consortium has now extended presence of SAM activity in Ludewa with SAM analysis done, feedback to authorities given and farmers mobilised to undertake advocacy in the near future.

MIICO shared some of their challenges which include the remoteness of the area, particularly Ileje, which makes it very difficult to access from Mbeya on a regular basis. This also hampers communication between the actors in Ileje as the area is not well connected with electricity and phones. For the case of SAM in Ludewa district, MIICO also reflected on the limited time available to undertake proper sensitization as the support had a restricted timeframe. The organisation is also finding that the vastness of the district geographically is a challenge as MIICO’s SAM interventions only cover 5 wards whilst the total number of wards stands at 23.

MIICO believe that SAM is an important tool in helping change the way things are done in LGAs as well as engaging civic actors. They also deem it important to involve council officials in the SAM analysis work so as to smoothen the advocacy process.

Sustainability of SAM activities in Ileje beyond the partnership with PF and SDC funding was a matter that was discussed in length at the MIICO offices. Participants recognised that it was important to enable the civic actors on the ground to continue and one suggestion was that perhaps closer collaboration with faith-based organisations, which are prevalent in Mbeya, could be explored as a possible solution to mitigating the risk of discontinuity. Another key point raised was that the right incentives for both demand and supply-sides of the accountability equation need to be outlined so that implementers can build on them. It was suggested, for instance, that the tangible positive changes in people’s lives (like walking fewer distances for service delivery) could be an appealing aspect for communities. This issue of sustainability also brought the point that it is important for programmes to think ‘exit strategies’ during their design phase.

The District Commissioner and her officials

The visit to the District Commissioner’s (DC) office on September 4th also helped the team to grasp a lot of issues from the LGA’s standpoint. The DC heavily focused her discussion on the staff recruitment problem. According to her, half the appointed personnel do not report to their posts. She mentioned that the Ileje District Council was trying very hard to implement their own retention strategy so as to keep the few who do report to the council. One of the key elements in their retention strategy is providing housing for newly-appointed staff although she said construction is very expensive. They had tried methods of receiving them very well to comfort them psychologically as well as making sure the community does the same. Another crucial element is that all of them receive their relocation/transfer benefits and salaries on time (not more than a week after moving to Ileje). These, she said, had even resulted in some appointees telling others in other districts about how well they have been received and treated.

The DC, however, mentioned two major and critical problems for the council: education and the state of the economy. On education, she said that Ileje was the worst performing in Mbeya with poor passing of students. As a marginalised area, the residents of Ileje have the lowest incomes. She reckons value addition of their produce can help bridge that gap with the rest of the districts in the region. On infrastructure, she said 19 villages were soon to be connected to electricity, according to recent Rural Electrification Agency (REA)plans for the district.

On CSO-government collaboration, she cited the support from MIICO/IRDO and how it helped the district a lot in terms of helping them address the many problems endemic in the area. She said that simply government alone would not have done some of the things MIICO/IRDO did. She mentioned, moreover, that every 6 months ILENGONET (Ileje NGO Network) meets with the district council to discuss issues and strongly recommended this type of collaboration for other districts.

On public participation, the District Community Development Officer said the council was trying hard to sensitize the community on the importance of their involvement in development activities but morale was still low. He gave example of how hey release information of income and expenditures (budgets) but they still do not read (during the visit to Chabu village, however, the visiting team saw out-dated budget information posted on the village noticeboard). He said the council had urged the community to build structures up to the window level, and they as government would complete them, (eg Shinji dispensary staff housing) but they find it hard to complete their contribution.

On enhancing accountability, the DC said that there were by-laws that the wards had introduced. For example, she said that it was not allowed for the councillor to stay up to six months with money unused. She also mentioned that councillors were being dismissed for lack of accountability as people gradually learn that they hold the power to do so.

Chabu: no need to walk to Malawi to attend health services

At the meeting with villagers of Chabu on the afternoon of September 4th, the team met two dispensary personnel who were already working and providing health services. After being introduced to them, we heard account after account of how difficult and dangerous it was in the past for villagers, including expectant mothers, to cross the Songwe River into Malawi for health services.

Despite the successes and the operational of the dispensary, the villagers appealed to the council to build the maternity ward as well as connecting the solar power to the staff houses and water tank to support growing water needs to staff and health facility.

Shinji: dispensary is ready but not operational

The situation in Shinji village was a little less triumphant because although the dispensary has been built and registered, it is not operational due to the incompletion of the staff quarters, wash rooms and more important, it is yet to be registered as required by health regulations. The villagers expressed dismay that although they have contributed enough of their own resources (labour, bricks, sand, stones) to the building meant for dispensary personnel, the council only gave 15 million towards the construction effort which was insufficient to complete the remaining work. The buildings are dilapidating and this fear was noticed in the discussion with villagers.

The villagers and their leaders pleaded with the visitors that their plight be communicated to higher places as they have done a lot to request the council help them with the completion of staff housing but nothing has been done thus far. The village chairman said he had written numerous letters to the DC without much action. During their visits to the village, the District Commissioner and Regional Commissioners indicated to have understood of their situation and promised to work on the matter.  To date, nothing has occurred in the direction of their prevailing situation. With a strong belief in media effects, the villagers were thinking of getting a journalist to write about the problem as they fear that if they pressed or demonstrated, the local council would arrest  and thrown behind the bar.

In response, the team stated that although primarily it was the duty of the villagers to demand for action from the government, MIICO would be writing to the DC to remind her of Shinji’s villagers’ plight.


The field visit offered those who had not gone to Ileje before more understanding of the SAM activities undertaken by MIICO under the partnership with PF and the achievements attained so far as well as the challenges encountered. More specifically, it gave the visitors a snapshot of the health service provision challenges in the district and how communities are coping with them. It was also an opportunity to closely see how bureaucratic bottlenecks can slow the speed of achieving development outcomes and what civic actors, once enabled and in certain contexts, can do to hasten it. As the Chabu case shows, highlighting the problem at all levels of government does help rectify an ublock endemic obstructions.

The trip was also a stern reminder that for citizens of Ileje district and elsewhere to effectively participate in the planning process, a lot more other things are required: enhancing general education levels, a less intimidating council apparatus and a more willing and responsive political leadership. It might seem that council officials are available to citizens to hear their concerns and respond to questions (as evidenced from the account of villagers of Shinji who were visited by officials to discuss why staff cannot report to their village). They are not, however, satisfying locals with the explanations given. This means that at the end, the council has to provide the social services and not culminate at simply holding meetings with the community. Moreover, it was also quite evident that behavioural change in citizens takes a long time to consolidate. Though there seemed to be willingness of citizens to convene in ample numbers, there seemed limited assertiveness among those outside the PF/MIICO sphere to demand explanations regarding the use of public funds. For this to happen across the district, a lot more persistence over time would be required.

This brings us to the issue of the sustainability of our interventions. With dwindling donor funds and the pressure to scale up to other areas, all actors involved need to critically think about how to get citizens aware of the significance of sustaining follow-ups on concerns and issues in their communities with much resource available within their means and minimal external resources.

Acknowledgements: Appropriate thanks to Ileje DC, Rose Staki Senyamule, Council staff, Chabu and Shinji Village chairmen and citizens of Ileje districts.

A full report on Policy Forum's Social Accountability Monitoring interventions is available in pdf format below:

Policy Forum's Documentary on Citizen's Participation in Improving Health Services-Chabu Village

[1] Foundation for Civil Society supports this initiative for improved service delivery in the agriculture sector from 2013-2015.

[1] MIICO is a Non-governmental and non-profit organisation based in Mbeya region. It was formulated in 2001 and attained the formal registration in April 21st 2005 under the Non-Governmental Organisation Act of 2002. MIICO is a membership organisation. It is formed by three member organizations known as Actions for Development Programs, Mbozi (ADP Mbozi), Ileje Rural Development Organization (IRDO) and Isangati Agricultural Development Organisation (IADO).