Recent work on medicine shortages in Tanzania provides a raft of examples of these complexities.
Many people in Tanzania were already aware that medicine shortages were a problem – having experienced it themselves or having friends or relatives who had suffered as a result of these shortages. More information might fill in the details for them, but it would not tell them anything particularly new.
Most also had their own strategies for coping with stock outs at public health facilities. Many people go to private medicine dispensaries – paying a premium for medicines that would otherwise be free or subsidised. People also contact local councillors, but generally do so because councillors can secure the transfer of more medicines to their facility from other areas or may sometimes acquire medicines for individual constituents in a semi-official capacity. These solutions are individual, rather than collective, and put pressure on an already overloaded system.
Some local governments have responded with major recruitment drives for local health insurance schemes. These give enrolled citizens free health care access in return for an upfront payment, with this money being matched by external donors and local government then being able to use these funds to buy medicines independently of unreliable government supply chains. Some officials prioritise medicines for those with insurance and set aside stocks to ensure they are supplied. These measures do little to solve the systemic problems behind the shortages, but provide localised relief, particularly for those who can afford the cost of insurance.
All of these examples demonstrate that citizens already have information and take action, and that local officials are already closely engaged in problem solving in their areas. What holds back longer term solutions is not a lack of information, but an inability to act collectively and develop systems that work in the best interests of the majority.
Our research therefore emphasises the need for strategies that can build collective action and a movement for accountability, strategies that require concerted efforts to find allies and construct coalitions across society.
Health officials and facilities who are having success in reducing stock outs should be recognised and highlighted, as well as poor performance criticised.
Alliances should be pursued between citizens, social movements and reforming officials. For example citizen monitoring can provide valuable information to track corruption and pressures on the system could be reduced if people committed to stop behaviours that worsen shortages – like demanding multiple medicines from doctors or buying government medicines on the black market.
This is not to say that all government officials or politicians are well intentioned or that the power dynamics created by patronage and party politics can be easily overcome. However, these obstacles can best be faced by alliances drawn from across both citizens and government officials – finding points of mutual interest around which co-operation can be built.
The global movement towards transparency and accountability has come a long way towards understanding the motivations of citizens and connecting them to collectively tackle issues.
In order for the full potential of the movement to be realised, it must apply the same logic and understanding to the agents of the state and work to build alliances with the reformers within.
We hope our research in Tanzania can help spur new debates and inspire new efforts to bring together coalitions of citizens and government officials.
The research was launched in Dar es Salaam yesterday by our research partner Twaweza and we look forward to following the debate in Tanzania over the coming months.
