Rude Forms of Accountability

Doing research in a rural government hospital in Bangladesh in 2006, colleagues encountered a poor elderly woman who was receiving treatment from a government doctor. It was one of those mass consultations – 20 or more patients crowded into the consultation room alongside relatives, infants, curious observers – for which government hospitals are justly infamous. The woman in question was unhappy with her consultation. She complained, to the room, that the doctor had not given enough time to her problem; he had given her the same advice previously, and it had not worked then either. Embarrassed by this public rebuke, the doctor responded by giving her a little more time and consideration. Later, when the woman was asked about her complaint, she denied that this was what it had been. How could, she explained, someone like me (poor, elderly, female) complain about someone like him (educated, elite, a government doctor)?

This poor elderly woman was capable of voicing her complaint across the differentials of social status and professional power that distance doctors from poor patients. Across that gap of status and power, she had succeeded in eliciting a slightly better consultation. Yet her denial that it was a ‘complaint’ was significant. Vast multimillion-dollar health sector reforms have failed to institutionalise any innovations in participation of or accountability to patients, yet the power of shame and a sharp tongue have the power to elicit an immediate and perceptible impact.

Indeed, formal accountability mechanisms fail citizens and service-users in Bangladesh in at least three ways. First, for many services, official mechanisms for enabling users to claim or complain do not exist. If, for instance, you believe you have been wrongly denied beneficiary status for a state safety net, and that a less needy person has been assigned one in your stead, there is no known official procedure through which to claim or complain. Formal accountability also fails in this context when mechanisms exist on paper or within official rules, but are not implemented. A third failure occurs when mechanisms formally exist and function, but fail to function as intended.

So people turn to rude forms of accountability: the weapons of the weak that range from the faintly impolite, to the downright abusive, to the plainly violent. This sense of ‘rudeness’ is plain enough, but there is another, equally significant sense in which these encounters are ‘rude’, or perhaps rudimentary; this is in how unmediated and unorganised – spontaneous, even – many of these reactions are.

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Related Resources

Rude Accountability in the Unreformed State: Informal Pressures on Frontline Bureaucrats in Bangladesh by Naomi Hossain, (2009), IDS Working Paper 319