Association for Public Policy Analysis & Management

This study contributes to the literature on the provision of health care in developing countries by proposing a theory of accountability that is rooted in communitarian tradition. The literature on improving the quality of health care in developing countries has emphasized the importance of empowering local communities to hold providers accountable (Björkman and Svensson 2009, 2010, Banarjee et al. 2010, Björkman-Nyqvist at al. 2015). The World Bank (2004) has embraced this community base-monitoring (CBM) approach as an alternative to electoral accountability.  Empowering community members to negotiate with healthcare providers the quality of health services reduces the need for oversight by the elected officials. And in so doing compensates for the failure of electoral processes to keep provider accountable.

Remarkably, although CBM approach was developed with explicit understating by the Western scholars and policy makers that the mechanism of electoral accountability that function well in developed countries may not produce the same outcome in non-Western conflict, these works never questions the applicability of individualism as the methodological paradigm to non-Western cultures.

This study uses a mixed-methods approach and Tajikistan as a case study to show that individual centric-explanations generate predications about individual interactions with the healthcare system that are not consistent with empirical observations. Specifically, using a survey data collected by the World Bank the study reveals that individuals in low-income countries, including Tajikistan, are less likely to complain about the quality of health service, than those in more developed countries. Then the study uses an original data from focus groups to develop a topology of individual embeddedness into traditional community institutions and household. This embeddedness subsequently shapes community members orientation with health care providers.  Therefore, both policymakers and scholars should pay a greater attention to the local context in which policy interventions are implemented.

This study relates to the theme of the APPAM conference by showing how local conditions constrain the international community attempts to improve access to health care. This paper would be a good match with papers related to improving poor people’s access to healthcare.