Social Accountability Initiatives in Health and Nutrition: Lessons from India, Pakistan and Bangladesh

"[T]he scholarly interest in accountability forms part of a recent tendency to document wider emergent forms of citizen action and community-driven development."

This research report is designed to be of particular use to practitioners of health and nutrition in South Asia who encounter challenges around weak accountability and poor governance. A range of accountability initiatives - categorised here as techno-managerial, transparency oriented, participatory, and collective or social accountability - has been implemented to improve service delivery in the health and nutrition sectors. The project synthesised in this report started from the overall premise that studies of accountability initiatives should be rooted in an understanding that the state is not distinct from society but is embedded in prevailing power dynamics and social relations. The researchers therefore looked to the existing critical accountability literature to understand the socio-political processes within which different types of accountability initiatives and movements emerge, are shaped, unfold, and influence socio-political change.

The report first summarises current concepts and issues in accountability thinking and practice, focusing on practices commonly referred to as "social accountability". In brief, the focus is on accountability-seeking processes originating in communities or at local interfaces between community members and political processes. The review classifies initiatives according to a broad typology of approaches (user-centred information access, complaint/grievance redress, citizen report cards, public hearings, community scorecards, community monitoring, participatory budgeting). Another review classifies such actions under dialogic and advocacy approaches, focusing on different stages of accountability processes (see Table 2). These social accountability initiatives (SAIs) address failures in the "standard model" of political and administrative accountability; the researchers point to ways in which reality often deviates from this standard model.

Against this general conceptual and theoretical backdrop, the report examines health systems in South Asia in the light of assumptions underpinning the standard model of accountability. As noted here, standard governance models work on the assumption that representative democratic systems will direct resources towards pressing health problems and that, where such systems fail, citizens or service users as "principals" can engage with the system via their "agents" (local leaders, politicians, etc.). However, without political will, commitment, and attention, many health issues remain both invisible (to the political system or to communities themselves) and ignored within the standard model.

They then identify a series of contemporary critical issues arising in social accountability literature and practice. For example: "Contemporary discourse on community participation in accountability argues that citizens should engage with the state as 'makers and shapers' of policies that affect their daily lives and locate themselves at the centre of accountability processes and targeted outcomes (Cornwall and Gaventa, 2001). The problem with a wide variety of these approaches, however, is that although they emphasise citizen action, they tend to emerge through a number of external 'initiatives' and 'interventions', which can carry the same relationships of power as those made visible by the critiques of participation." Some of these issues came to light in studies seeking to ascertain the factors that influence the effectiveness and impact of these approaches, and offer pointers for how to design and implement initiatives for maximum impact. Others include the importance of context (particularly socio-political context) in shaping accountability initiatives and how they unfold. They also include clientelist or patronage political cultures, which refers to the barter of political support for direct individual profit (politicians in clientelist linkages set up elaborate devices and mechanisms to monitor the voting behaviour of clients and to ensure their accountability.

The report then sketches some of the accountability issues facing the health and nutrition sectors in India, Pakistan, and Bangladesh, before homing in on social accountability practice in the three countries. The researchers present findings from a more focused review of academic and 'grey" literature, followed by a summary of an online consultation with practitioners involved in these fields in each country. The discussion started by focusing on the question: How do organisations on the ground ensure that community members are engaged and lead social accountability efforts? In brief, participants illustrated how all social accountability processes begin with raising awareness and informing community members of their rights and entitlements. This step entails building a "culture of questioning" wherein communities are mobilised around issues of health care and basic services. The awareness-raising aspect is not limited to specific rights and entitlements, but includes building awareness on wider social and policy structures, the role of democracy, and the way the state functions. Some organisations engage with frontline service providers during this stage. Participants observed that community participation can deploy a range of tools. Participants mentioned the full range of activities noted in the literature review (community scorecards, social audits, etc.) but also mentioned uses of information and communication technologies (ICTs) (see page 21) and pictorial materials/flashcards as ways to ensure inclusion of illiterate people. Participants were keen to underline that the effectiveness of social accountability tools does not depend on the type of tool chosen, but on the strategy built around it.

Other questions explored during the consultation (and in the report) include:

• How are community members involved in negotiating with the state?
• What are the different ways of promoting accountability of private providers?
• What should be done when patient rights are violated through private sector actions?
• What are the ways of ensuring rational and ethical practice that has the potential to safeguard patients' rights?
• How do standard ways of understanding the impact of SAIs look, when viewed from community members' and practitioners' perspectives?
• What roles can community members play in monitoring change?

"To sum up the rich contributions of participants over the two days of online discussion, we can say that the main message might be that putting politics and power at the core of the accountability discourse is essential to 'make sense' of the change we seek to create, and any attempt to understand impact should take into account these considerations." Some of the key themes from the consultation (and earlier literature review) are echoed in two case studies that follow: the Right to Food (RtF) movement (catalysed through legal mechanisms and mobilisation of communities and organisations at a national scale in India) and Naripokkho (from community activism and accountability to state-level action on women's rights and development in Bangladesh).

The concluding section of the report features a discussion of four key considerations for the design and analysis of such programmes:

• The need to understand community heterogeneity - "The practitioner consultation highlighted...issues with inclusion, recognising the need to listen to particular voices - especially (but not exclusively) women's voices - whether via general mobilisation or specific and separate consultation with groups who are unlikely to otherwise be given a voice. The consultation also stressed the need to mobilise and sensitise communities around specific issues - something that resonates with the wider literature on the need to highlight the less visible and lower-profile community issues such as chronic undernutrition, for example."
• The role of community collective action and/or its role in coercion or "noisy protest" in effecting change - "The consultation highlighted how choice of action might depend on both formal and informal styles or registers of communication but also whether the action aims to secure change at the local or national level. Participants highlighted the need for multi-level action or 'vertical integration' between actions at the various administrative levels of government, from village to district to state. The two extended case studies...provide useful examples of community accountability joining with wider civic and legal action and national-level political movements to pursue effective change simultaneously at these multiple levels."
• The ways in which cooperation, capacity, and commitment affect the community and frontline provider relationship, and the ability and willingness to deliver to meet demands - "[I]n the cases cited by practitioners in the online consultation, deliberate involvement in accountability - rather than being a threat - has been part of the story of empowering frontline workers or lower-level functionaries to contribute to local movements for positive change."
• The ways in which clientelism and other such extant local political structures form the backdrop against which accountability actions play out - "[H]ow these institutions function is critical to understanding how poor people and groups of poor people usually experience the everyday workings of the state."

In concluding, the authors note that, "in this project we have struggled to meet our ambition of providing further and more nuanced accounts of how external interventions might interact with existing political structures in ways that are not always anticipated by the originators of accountability interventions....In future, a more nuanced assessment will be important in gaining a greater understanding of the factors that determine whether accountability initiatives succeed, fail, have unintended consequences and /or are sustained beyond external intervention and momentum."