As part of a civil society alliance trying to apply rights-based approaches, there has often been a struggle between getting normative statements politically endorsed in laws or covenants, and the experience of applying them in practice. Normative statements often have limited impact on the ability of poor communities to get themselves recognized as genuine ‘rights holders’ and to be able to exercise the rights or claim state accountability for ensuring them.
Political statements of human rights such as UN treaties and laws are important at the discursive level in terms of setting global or national standards, and they symbolize a public acknowledgement of the ‘wrongs’ that prompted the codification of the ‘rights.’ But in the actual process of realizing rights, there are imbalances and complexities in the relations of power between service providers and users [14
] or, in human rights language, the rights claimants and the duty bearers. Reviewing understandings of rights, Yamin notes that human rights language has largely maintained an understanding of human beings as autonomous individuals, without fully appreciating how social relations constitute structures of choices within which people perceive, evaluate and act [16
]. A case in point is rights conferred on poor women in contexts where they have limited access to the means to actualise their entitlements and where they are often not seen, and do not see themselves, as worthy of having rights [17
Elite biases in policy making result in skewed distribution of basic services that reflects the lack of voice of the poor in determining the types of public services that should be available, their physical location, terms of access to services, and nature of interactions between providers and users. This lack of voice, in turn, stems from a failure in representative politics. In the context of governance, ‘voice’ is understood to describe how citizens express their interests, react to governmental decision-making and respond to problems in the provision of public goods like healthcare [14
Provider-patient relationships are also deeply influenced by the social context in which they are embedded. Where there are high levels of poverty and inequality, the social and economic status differences between providers and service users affect the capacity of poor users to obtain good quality and respectful services, and the unequal power relationship between experts and clients may be exploited by the former in their own interest [18
]. The poor are likely to have to travel great distances for treatment, may be obliged to pay bribes to be seen by a health professional, may not receive appropriate treatment or may even be humiliated, and face contemptuous treatment by service providers [14
It has been argued that the accountability and responsiveness problems among service providers are a product of difficult work conditions and an inadequate or non-existent professional service ethos. Workers who are demoralized, under-paid, and poorly resourced will seek to control the variety of demands which clients place upon them by limiting the information and services provided to socially marginal service users [14
]. In fact, the poorer class of service users may be under more pressure from providers to pay bribes, because of their low social status and perceived lack of capacity to organize to expose corruption or press complaints.
Abusive treatment of service-users is enabled by failures in formal and informal accountability systems. Formal systems of administrative control, performance assessment, and grievance-redress usually fail to register or punish maltreatment of patients, citing lack of formal complaints. Poor patients on the other hand, rarely register formal complaints for fear of victimization and further abuse. In fact there are often anti-poor biases built into the direct accountability mechanisms, such as judicial remedies. When the agents claiming accountability happen to be poor and/or socially marginalised groups with few social and political resources at their command they are unlikely to be a counterweight to the considerable power of public officials and institutions. When these agents happen to be poor women the power equation can become even more unbalanced [17
In the language of governance, the term accountability has two dimensions, answerability
, when someone is obliged to explain their actions or decisions, and enforceability
, when sanctions or punishments can be applied in case the answers are not satisfactory. In the practical operation of accountability systems there are two kinds of accountability: vertical
forms, in which citizens and their associations play direct roles in holding the powerful to account, and horizontal
forms, in which the holding to account is delegated to other powerful actors [19
]. Normatively, public sector actors have a duty to be responsive
to the members of the public with whom they interact, but are obliged to account
for their actions only to their seniors, who are accountable upwards to the legislature and the executive, to financial auditors, and to higher court judges [14
Vertical accountability is where the state is being held to account by non-state agents. Beyond elections, there are other processes through which citizens organize themselves, demanding explanations and threatening less formal sanctions like negative publicity. Horizontal accountability, on the other hand, consists of formal relationships within the state itself, when one state actor has the formal authority to demand explanations or impose penalties on another state actor. But there are always failures in reporting, audits, and disciplinary procedures within service bureaucracies; the checks on impropriety which should occur via the upward flow of reporting and accounting are easily undermined by collusion between superiors and subordinates.
Citizen participation has been defined as a political process that seeks to challenge exclusion from processes and decisions that affect people’s lives and health by placing a limit on power of elites to impose their own will [14
]. When previously excluded or overlooked social groups demand more direct accountability, it challenges the elitist biases which may have produced their exclusion in the first place. Yamin [16
] calls for distinct approaches to participation, which centrally include fostering “critical consciousness” as a precondition to effective participation. With appropriate tools and informed choices, citizens can construct claimed or demanded spaces for claiming citizenship entitlements. In this conceptualisation, participation is not merely a means by which given citizenship roles are reproduced and state obligations fulfilled, but rather, it offers the prospect that citizenship “can be claimed from below” by women and other marginalized groups “through their own efforts in organized struggles, rather than waiting for it to be conferred from above” ([16
] however cautions against putting the entire onus of vigilance on those who have the least time for, and the most to lose from, challenging the local power structure on which they most likely depend, and raises ethical questions about asking those who have the fewest defences, to take the greatest risks. In a context where public officials do not see themselves as subject to accountability, and do not recognise groups of poor women as agents making moral and social claims, merely eliciting a broader expression of the voices of women will not produce changed policies or change the behaviour of bureaucrats, the police, or politicians without concurrent changes in the norms and procedures of accountability institutions.
Making women’s voices heard, respected and responded to, without the formal means to do so, thus becomes the main challenge; however, the role civil society can play is dependent to a great extent on the nature of the political system and culture, and state-society relations. As a response to these challenges, civil society organisations in India in recent years have attempted to become involved in the state’s horizontal
accountability institutions or worked to create new institutions, or attempted to substitute for failed accountability institutions by holding their own enquiries and hearings [21
]. New ‘hybrid’
forms of accountability are also emerging in a number of recent examples that suggest insights as to how citizens might prompt more satisfactory performance from authorities, as they demand answerability
even if they do not have enforceability
. Mukhopadhyay and Meer [17
] suggest that they can do this through building strategic alliances and by drawing on the legitimacy they build up over many years as development actors in civil society.