Strengthening Social Accountability to Improve Reproductive Health and Family Planning Services

"Results from both projects show promising improvements in the relationships among health service providers, municipal leaders, and citizens that can lead to tangible collective community action to improve health service delivery, ultimately improving demand for and uptake of health services."

In West Africa, West Africa Breakthrough ACTION (WABA) and Resilience in the Sahel Enhanced (RISE II) are working to increase the use of reproductive health (RH) and family planning (FP) services, using approaches such as social accountability to encourage ordinary citizens and/or civil society organisations to hold elected leaders and government entities answerable to their commitments. In the health sector, social accountability approaches seek to improve health service quality, delivery, and outcomes. From Breakthrough ACTION, this technical brief presents the WABA and RISE II project experiences in addressing social accountability while implementing community engagement efforts in the context of social and behaviour change (SBC) for health.

As the brief outlines, social accountability tools and approaches encompass a broad range of interventions, with diverse designs and democratic principles that allow citizens to have a voice regarding decisions that impact their lives, including how public services are designed, delivered, and maintained. Civic engagement increases transparency, fosters greater civic voice and participation in public service delivery, and supports social accountability tools and approaches, such as patient charters, exit interviews, user committees, community scorecards, and talk-back radio (see Annex 1 in the brief). Both WABA and RISE II used a combination of patient charters, community dialogues and the community action cycle (CAC), data for decision making, and community feedback.

More specifically, WABA and RISE II implemented similar community engagement approaches in Burkina Faso, Côte d'Ivoire, Niger, and Togo. In brief:

• RISE II applied the traditional CAC approach, which included a community entry phase involving community buy-in and organising for action under the auspices of the multisectoral community mobilisation team (MCMT). Niger and Burkina Faso held over 100 community entry meetings attended by 14,000 people (over half of which are women) from 80 communities. As a key outcome of the community entry process, village representatives verbally expressed and affirmed their commitment to the process during an official ceremony. The MCMT helped stakeholders in Niger develop health centre community action plans, while in Burkina Faso, each village developed an action plan that they shared with the broader community and district officials for input and validation. The MCMT provided coaching and supervision to guide the health committee and community in fulfilling these actions. When the action plans reached completion, the district-based MCMT invited the community and the health facility stakeholders to use participatory tools (i.e., scorecards and quick key informant interviews with local actors) to compare achievements against key indicators. The MCMT in coordination with community members amplified findings through community radio and other community media, allowing more distant members to participate in collective community action for improving health outcomes.
• WABA started at a phase involving exploring health issues and setting priorities, featuring integrated community dialogues and health centre walkthroughs that provided an intimate space to speak openly and honestly and dispelled rumours about how services are offered. WABA then moved to a "plan together" phase by developing joint action plans that provided a variety of community members, including marginalised people, with a voice on how to improve health services to meet their needs. As a result, across the four WABA countries, communities developed, implemented, and updated 84 facility-based community action plans addressing the barriers to FP/RH service uptake, such as reorganising spaces to ensure client privacy. Instilling a culture of taking stock of what has been implemented, reporting back, and sharing feedback between service providers and community health committees has reportedly improved accountability among stakeholders in the health catchment areas.

Both WABA's and RISE II's approaches focused on problem-solving through collective action, which created an opportunity to incorporate social accountability within communities and between health service providers and community members. These approaches increased demand for improved health services in the following way: Community engagement interventions enabled citizens to engage with health providers (in person or through meetings) to discuss necessary improvements in health services. These processes created positive changes in service quality, including improved conditions for health workers, increased health worker performance, positive interactions with health system users, and improved health facilities - all of which ultimately increased demand for health services. For example, WABA implemented a referral coupon activity in sentinel sites, where data over the past three years suggests that this intervention contributed to the uptake of FP services.

The following are key insights learned through these projects:

• Government sector staff with demonstrated facilitation skills encourage social accountability.
• Multisectoral participation ensures multi-level engagement and outcomes.
• Linking social accountability and community engagement initiatives to the municipality and local council mandates can accelerate positive change.
• Training community members to strengthen their skills and communication skills gives them greater confidence to demand social accountability from themselves and their leaders.
• Measuring social accountability can be difficult but is not impossible.
• Improving advocacy capacity as part of the community engagement initiatives may assist communities and health centre personnel in improving accountability with local leaders and technical officials.
• Investing in public sector structures secures a position for community engagement within the government system, but it may not be the most effective way to ensure sustained social accountability.

Three broad categories to advance the field include: (i) a shared understanding of viable social accountability approaches, (ii) implementation standards, and (iii) coherent ways to measure social accountability.

In conclusion: "Social accountability approaches use civic engagement and community participation to empower responsible citizens and organizations to improve service delivery that, in turn, improves health outcomes. Further, building a shared understanding of effective community engagement interventions and standards may enhance social accountability as part of SBC and health system programming.