Citizen's Charter in a primary health‐care setting of Nepal: An accountability tool or a “mere wall poster”?

Abstract Background Despite some empirical findings on the usefulness of citizen's charters on awareness of rights and services, there is a dearth of literature about charter implementation and impact on health service delivery in low‐income settings. Objective To gauge the level of awareness of the Charter within Nepal's primary health‐care (PHC) system, perceived impact and factors affecting Charter implementation. Method Using a case study design, a quantitative survey was administered to 400 participants from 22 of 39 PHC facilities in the Dang District to gauge awareness of the Charter. Additionally, qualitative interviews with 39 key informants were conducted to explore the perceived impact of the Charter and factors affecting its implementation. Results Few service users (15%) were aware of the existence of the Charter. Among these, a greater proportion were literate, and there were also differences according to ethnicity and occupational group. The Charter was usually not properly displayed and had been implemented with no prior public consultation. It contained information that provided awareness of health facility services, particularly the more educated public, but had limited potential for increasing transparency and holding service providers accountable to citizens. Proper display, consultation with stakeholders, orientation or training and educational factors, follow‐up and monitoring, and provision of sanctions were all lacking, negatively influencing the implementation of the Charter. Conclusion Poor implementation and low public awareness of the Charter limit its usefulness. Provision of sanctions and consultation with citizens in Charter development are needed to expand the scope of Charters from information brochures to tools for accountability.


| BACKGROUND
An informed citizenry is a precondition for demanding accountability from service providers. 1 Theoretically, citizen's charters are part of the New Public Management approach and are initiated to encourage service providers to be responsive and to inform citizens about service entitlements, standards and rights. 2 This approach envisages each citizen as a consumer and emphasizes individualism rather than collective notions of citizenship. 2,3 Citizen's charters were first implemented in the United Kingdom in 1991. 2,4 Soon after, the charter concept was adopted in various developed and developing countries. 5 Although the central aim was to achieve better quality and a responsive service delivery, there are differences in intent, content and implementation in different countries. 6 Despite the concept being variable, charters can be powerful accountability mechanisms, facilitating the expression of citizens' expectations of service providers.
Nepal's primary health-care (PHC) system includes networks of nearly 4000 peripheral health facilities. 7 Health facilities include subhealth posts, health posts and PHC centres managed by district (public) health offices. 7 These health facilities predominantly provide preventive and promotion services, with few curative services. 8 A subhealth post is the first institutional contact point for basic health services. 8 A community-based service is provided by Female Community Health Volunteers (FCHVs) and outreach clinics managed by these health facilities. 8 Subhealth posts act as referral centres for FCHVs and outreach services, which, respectively, refer on to health posts, to PHC centres and finally to hospitals. 8 To ensure community voice in health facility management, health facility operation and management committees (HFMC) were formed in each these health facilities to manage funds, human resources and health programmes. 9 In line with global trends, Nepal introduced the Citizen's Charter in 1998 as a reform initiative to modernize public service delivery. 10 Nepal adopted a similar model to the United Kingdom. In the early 2000s, Nepal implemented Charters in PHC facilities. 1 Citizen's Charters were uniform across all the health facilities.
Despite some empirical findings about the usefulness of charters with respect to awareness of rights and services in both developed and developing countries, [11][12][13][14][15] there is a dearth of local literature about charter implementation and impact on health service delivery, particularly in rural settings. This article seeks to address this knowledge gap by reporting on awareness of the Charter, perceptions of the Charter's impact on transparency and accountability, and factors affecting the implementation of the Charter in a district in Nepal.

| Study setting
This case study (2014)(2015) was conducted in Nepal's predominantly agricultural Dang District, located 280 km west of Kathmandu ( Figure 1). 16 Ecologically, the district contains both diverse topography and ethnicities. It has a population of approximately 550 000; nearly 80% live rurally. 16 The literacy rate is 70%. 16

| Data collection
This study was carried out as part of a larger project investigating social accountability mechanisms. Following pre-testing, a structured face-to-face survey was administered by interviewers to 400 participants (220 service users, 100 HFMC members and 80 service providers) selected by two-stage cluster sampling from 22 of 39 public health facilities in the Dang District. Selection of health facilities (clusters) at the first stage was used to reach the main sampling units (service providers/HFMC members/service users). Health facilities were stratified by subhealth posts, health posts and the PHC centres. Then, 22 health facilities (nine subhealth posts, 11 health posts and two PHC centres) were selected randomly from each strata. Service user flow of each sampled health facility was calculated, and the number of the service users to be interviewed in each health facility was determined in proportion to size. The required sample per health facility was selected systematically. Only five invited potential participants declined to participate. With respect to all potential HFMC members and service provider participants (n=219 and n=114, respectively), those available on the day of interview were approached and all those invited participated.
Questionnaires focused on gauging the awareness of health service providers and community people towards the Citizen's Charter.
Awareness was assessed by knowledge of the existence of Charter in the health facility and understanding of the Charter's main features.
Participants answered "yes" or "no" to a question asking whether they heard of the Charter in their health facility, and questions asked about the key features of the Charter which include types of services available, costs, time to receive services, complaints person, facilities and timetable of service hours. In addition, an audit was conducted at the 22 sampled facilities using a checklist to assess availability and visibility of the Charter.
The qualitative component of the study explored how Citizen's Charters were implemented, their perceived impacts and factors affecting the implementation of the Charter. Thirty-nine interviews using open-ended interviewing techniques were undertaken with HFMC members, service providers (health workers from the PHC facilities), district-level health managers and non-government organization (NGO) members. Six focus groups were also conducted with community people (one group with men, four with women and one with FCHVs). An interview guide included a list of topics and questions to be covered. Collecting data from diverse people with different backgrounds enabled triangulation of study findings. 17

| Data analysis
Pre-coded quantitative data from the questionnaires were entered, checked for data quality and analysed using IBM SPSS Statistics 22. 18 All the qualitative interviews and focus groups were audio-taped, transcribed and analysed using NVivo 10. 19 We used thematic analysis which included familiarization with the data by reading transcripts, open coding, development of coding framework and labelling data under the appropriate codes. The coded transcripts were summarized in narratives for each theme.

| Ethics
We obtained ethical approval from the Human Ethics Committee of Otago University and the Nepal Health Research Council. Informed consent was obtained from all participants.

| Socio-demographics of participants
Among the 220 service users interviewed during the survey, 66% were female with a mean age of 33.7 years (range 19-81 years) and more than two-thirds (68%) used the health facilities for curative services.
The majority (59%) were formally literate, and main occupations were those of housewife worker (41%) and agriculture worker (35%). In the case of service providers (n=80), most respondents were female (55%) and permanent workers (64%) with the mean duration of service of 11.5 years (SD 9.52; range=1-38 years). In the case of HFMC (n=100), the majority of the members were male (62%) and literate (91%), with a mean duration of service of 4.3 years (SD 3.8; range=1-20 years).
Of the 39 qualitative interviews, there were 34 male and five female participants with participation from community, health facility and district levels. Most of the participants were HFMC members (15), followed by service providers (10), NGO staff/members (10) and district-level managers (4). Additionally, 56 participants (8 men; 48 women) made up the six focus groups; each focus group consisted of 8-13 participants. There was one male focus group, whose members were ordinary citizens affiliated with different professions and also service users from the nearest public health facilities. Among the four female focus groups, most members were affiliated with community mothers' groups or were service users. The one FCHV focus group participants represented different wards of the village development committees.

| Knowledge of Citizen's Charter
The great majority of HFMC members (84%) and service providers (90%) had heard about the Charter. However, only 15% of service users reported awareness (Table 1). There was a tendency for men to be more aware of the Charter. A greater proportion of service users who were literate had heard of the Charter compared to those who were illiterate, and there were also some differences according to ethnicity and occupational group. Of the service user respondents who had heard of the Charter (n=33), two-thirds (n=22) had actually read it.
The interviews and focus groups also revealed that the majority of the citizens were not aware of the existence of the Charter in their health facilities:

| Knowledge of participants on the main features of the Citizen's Charter
There is a guideline about the minimum information to be incorporated in a Nepalese Citizen's Charter. 20

| Source of knowledge about the Charter among service users (n=33)
Respondents knew mostly about the Charter through displayed perspex sheets (52%) followed by radio/television information (36%) (Figure 3). However, they felt that FCHVs (58%) and radio/television (55%) would be the preferred means of learning about the Charter. Although they had not heard about the Charter from HFMC, 15% of the respondents perceived that the HFMCs would also be a useful way of being informed about the Charter.

| Perceived impact of Citizen's Charter
In the survey, service users were asked about the overall usefulness of the Charter in terms of informing them about health facility services.
Qualitative components explored in more detail the usefulness of the Charter in holding service providers accountable and improving health service delivery.

| Usefulness of the Charter in learning about the service
The survey showed that of the service user respondents who had heard of the Charter (n=33), 20 (61%) believed the Charter was readable and understandable for only a small proportion of the general public. However, a good majority of service users (67%) felt that the Charter was helpful to some extent in getting information about the service they wanted from the health facility.

| Role of Charter in transparency
Interviews and focus groups showed that the Charter was seen as a potential tool to increase transparency, particularly for those who were educated and had a habit of reading information. However, the

| Role of Charter in raising citizen's concerns
It is plausible to think that citizens can complain if a service is not provided in accordance with the standard mentioned in the Charter.
However, such an assumption did not hold true for the Charter in this study. One of the health post managers commented, "I have been serving here for five years, but no one has ever asked me about why service in the Charter is not available in the health post" (Qualitative interview, clinic manager, subhealth post 2).

| Role of the Charter in improving service providers' accountability
Interviewees generally perceived that Charters were found to be of limited use in holding service providers accountable:

| Factors affecting the implementation of the Charter
Eight different factors emerged from the qualitative component as af- fecting the implementation of the Charter: lack of proper display, lack of consultation with stakeholders, lack of orientation or training, no follow-up and monitoring, lack of enforceability, service providers' attitude and illiterate citizens.

| Lack of proper display
The health facility audit showed that the Charter was found in 19 (86%) The reasons reported for not displaying the Charter outside the health facilities included the following: information secrecy by health workers and fear of it being stolen or getting damaged.

| Lack of consultation with stakeholders
The implementation process was top-down. Consultation with citizens while designing and implementing the Charter was non-existent.
Hence, very few citizens knew about the existence of the Charter.

| Lack of orientation or training
There was no orientation or training provided to either health service providers or citizens regarding the Citizen's Charter. Hence, many respondents understood it as a mere information tool just like other posters hung on the wall, but not as an accountability tool.
There is no orientation for us about why the right to informa-

| No follow-up and monitoring
The practice of follow-up and monitoring of the implementation of Charter was almost non-existent. In addition, the indicators related to Charter were not included in the integrated supervision and monitoring checklist of the district health system: There is never a discussion about, or monitoring of, the

Charter. There is no discussion on whether it is displayed
properly or what its effect is.

| Service providers' attitude
It was found that service providers' attitude and information secrecy was another reason for poor implementation of the Charter. For example, service providers gave little emphasis to the Charter as they did not feel responsible for providing services according to the Charter, and the implementation of the Charter was top-down. In some cases, they were found to intentionally not display the Charter in a visible place promoting information secrecy: The main problem is the mentality of the health workers that they are not ready to take responsibility and to pro-

| DISCUSSION
The main aim of this study was to understand the level of awareness of the Charter, the perceived impact and factors affecting the implementation of the Charter in a rural and remote PHC setting, using the Another key assumption about a charter is that it informs citizens about their rights so they can, in turn, exert voice or make complaints about service providers to improve performance 1 which is also found to be poor in the present study.
Most importantly, in contrast to findings from a health facility charter in Kenya, 15 the Charter's role in improving health service provider accountability and health service improvement was not strong in Nepal. Kenya. 15 While a citizen's charter is intended to be an accountability tool oriented to rights of the individual rather than at the collective notion of citizens, 2,3 in a health-care context in a developing country, it appeared that use of such individual accountability mechanisms may not be entirely appropriate. In contexts where many citizens are illiterate and not empowered and there is no strong tradition of consumer rights, 2 mechanisms which emphasize an organized participation of citizens for collective goals may be more appropriate to enhance service providers' accountability. 24,25 In contrast with other studies on citizen's charters, which were mostly from outside the health service delivery contexts, 5,10-12 this study adds new insights by exploring the level of awareness and perceived impact of the Charter and by identifying the design and implementation challenges of the Charter in a health system context. As the charter concept is adapted from developed countries, this study highlighted the relevance and challenges of implementing the concept in a rural and underdeveloped service delivery context. Hence, these findings provide a useful evidence base to strengthen the charter concept in health service delivery in rural and low-income settings. A number of policy and practical implications arise from the findings. These include the following.

| Consultation with stakeholders
Consultation with citizens and front-line service providers while designing and development of the Charter is necessary. Such process would give an opportunity to design the Charter based on local needs, build trust and support for its implementation and raise awareness of the Charter.

| Provision of sanctions in the Charter
There needs to be provision within the Charter to take appropriate action if health services are not according to the standards mentioned in the Charter. A functioning grievance redress mechanism should be established. 2 Such provision within the Charter would likely help improve service provider accountability and service improvement.

| Orientation and training to service providers and HFMC members
The concept of the Charter was not properly understood, and there was a need to change the mindset of service providers. Orientation and sensitization to service providers and committee members seemed important to make them aware about the concept and spirit of the Charter.

| Monitoring and follow-up of the Charter
The Charter initiative remained a one-shot activity with lack of followup and monitoring of how it is implemented or its effectiveness. There is a need to develop a mechanism to monitor its implementation by integrating activities related to the Charter in existing supervision and monitoring checklists of the district health system.

| Strengths and limitation of the study
Strengths of the study include that data were collected from participants with different backgrounds representing different levels of health facilities and varied geographies which helped to triangulate the findings. Furthermore, the lead author himself was involved in conducting all the qualitative interviews which helped ensure a deep understanding of the phenomena. However, this study does have limitations. There may be a number of response biases while conducting a questionnaire survey due it being based on personal opinion.
However, pre-testing of the questionnaires and training of research assistants (who were locals) helped to reduce the biases. Although we wanted to include the perspectives (voices) of service users and the general public in the qualitative component of the study, due to the Charter concept being relatively new and complex, we recruited more service providers and HFMC members who were thought to be "information-rich" sources. 27 Furthermore, we included the perspectives of service users/general public in the focus groups and survey interviews. It was not possible in this cross-sectional study to measure the impact of the Charter against health service delivery improvements. With the maturity of the Charter implementation process, a future study could inform in the impact of the Charter programme in different aspects of health service delivery.

| CONCLUSION
Poor design, development and implementation, and low public awareness of the Charter have limited the function of the Charter a mere information tool. Unlike its relevance in developed countries, one wonders whether the Charter concept is really an effective transparency and accountability tool in the health-care context of developing countries like Nepal where a significant portion of the citizens are illiterate, 28 where the culture of seeking information by reading information is not well established, and where consumer rights have not been well explained. That said, provided adequate attention is given to design and development of the Charter, to implementation and monitoring and to linking the Charter to health service improvement, it seems there is potential to realize the Charter's values and principles.