The Millennium Development Goals (MDGs), international goals agreed at the United Nations (UN) Millennium Summit in 2000 and covering the period from 2000 to 2015, have contributed to increased investments in basic services, such as health. The international community, led by the UN and in particular the World Health Organization (WHO), is currently involved in a debate about the nature of the post MDG agenda for health . It is suggested that the new development framework for health emphasizes people-centered and rights-based approaches with a focus on building equitable, accountable and sustainable health systems . The respect, promotion and fulfillment of the right to health by governments and its translation into local practice is a key challenge of the new era. In this context, an important question is how to hold states accountable for meeting their commitments to improving, for example, equality and non-discrimination in health care. One way of doing this might be to strengthen the role of citizens in the monitoring and review of the actions and decisions of policymakers and providers at international, regional, national and local levels .
Social accountability (also called citizen-driven accountability or bottom-up accountability) refers to the strategies, processes or interventions whereby citizens voice their views on the quality of services or the performance of service providers or policymakers who, in turn, are asked to respond to citizens and account for their actions and decisions. These efforts may be supported by governments, civil society, media or other actors [4, 5]. The approach aims to enhance the responsiveness of health providers and policymakers to citizens’ demands. The relevance of social accountability can be analyzed from two perspectives. From an institutional economics perspective, social accountability is seen as complementary to administrative or bureaucratic accountability, which has government-led or regulatory mechanisms of monitoring. From this perspective, one of the key challenges to accountability in health systems is the principal-agent issue, namely that national state actors cannot be fully held responsible for performance because of the multiple, hierarchical levels of delegation. Front-line health workers in primary health care operate at the lowest level in the hierarchy and have a certain degree of discretion in their decisions and actions, which cannot be controlled by the principal . In settings with a poor regulatory capacity, government-led monitoring and accountability mechanisms hardly exist and there is an increasing expectation that social accountability might be able to compensate for that gap and exercise some form of control [7, 8]. Parallel to this institutionalist perspective, social accountability has roots in several broader trends in development, including in rights-based approaches and participatory governance . These social movement approaches emphasize the voice, agency and collective action dimensions of accountability [10, 11].
Depending on the perspective, the expected results of social accountability initiatives can vary, but include a reduction in corruption; better governance and policy design; enhanced voice, empowerment and citizenship of marginalized groups; responsiveness of service providers and policymakers to citizens’ demands and, ultimately, the achievement of rights, health and developmental outcomes [4, 10, 12].
Citizen-driven accountability has been promoted over the past few years and some positive results and critical lessons have been reported for service delivery [4, 6, 13–15]. There remain, however, a number of questions regarding how social accountability interventions are conceptualized, how they work in practice across contexts and how they can be evaluated. The aim of this study is to review and assess the available evidence of the effect of social accountability interventions on providers’ and policymakers’ responsiveness in health service delivery and policymaking in countries with medium to low levels of governance capacity and quality. The reviewers are particularly interested in how social accountability interventions work and under which conditions they lead to specific outcomes.
This realist synthesis constitutes the first phase in a larger research program in sub-Saharan Africa on social accountability in maternal health service delivery. This program is being implemented in countries with poor governance capacity and quality, including those in post-conflict or fragile settings, such as Burundi, the Democratic Republic of Congo, Mali and Guinea. The results of this synthesis will inform the empirical research phase of this program; it will in particular support the identification and selection of case studies and inspire the development of evaluation methods. In addition, the results of the proposed review may be useful for development organizations engaged in health system strengthening, social accountability initiatives and rights-based approaches to health, both internationally and locally. This includes non-governmental organizations (NGOs), civil society organizations (CSOs), and their funders and networks. The findings may support reflection on the design and implementation of development programs by reporting on the challenges social accountability interventions encounter in specific contexts. From a conceptual perspective, this review will support the positioning of social accountability dynamics in the wider accountability debate in basic service delivery.
A realist perspective
An evaluation of the effectiveness of social accountability interventions faces a number of methodological challenges, of which an important one is related to complexity. For example, interventions, such as citizen complaint hotlines or citizen scorecards that require the public disclosure of performance, are expected to increase the incentives for service providers to perform. However, interventions take place in existing interaction spaces where there may be other formal and informal incentives for citizens to voice their concerns and public agents to listen to those concerns [11, 16–18]. For example, health policymakers or service providers may be triggered to become responsive by feelings of moral obligation or by fear of sanctions from superiors or a combination of both [17, 19]. The objects of citizen engagement are very diverse as are the participants in citizen engagement strategies. For example, the emergence of a citizen voice may depend on the frequency of service use or the availability of provider choice . In addition, voice and responsiveness dynamics will play out differently for claims of neglect and avoidable death than for demands to reduce waiting times . Health providers and policymakers may respond differently to men and women and to poor and non-poor demands, which Goetz and Gaventa (2001) call ‘exclusive responsiveness’ [21–24].
As these examples illustrate, the outcomes of interventions are highly dependent on human agency and context and interventions do not linearly produce outcomes. Many sources of complexity and subtle behavioral dynamics remain hidden in standard methods of systematic review, which focus on the assessment of outcomes (does it work?). In complex interventions, such as social accountability, standard systematic reviews have limited value for transferring lessons from one context to another . An alternative is to distill how, for example, health system characteristics or intervention components (context) influence individuals to act in certain ways (be responsive to citizens or not) to produce certain outcomes (improved quality). This alternative method of realist review can, to a larger extent than standard systematic reviews, explain how context influences the outcomes of interventions [26, 27]. This method seems most appropriate for our evaluation of social accountability interventions.
Realist synthesis is rooted in realism and critical realism within philosophy and the social sciences. It is a logic of inquiry that is theory driven and that facilitates an explanation of what works, for whom, in what circumstances and in what respects . Philosophers such as Bhaskar, Archer, Merton, Campbell and Popper have inspired the development of a realist approach (see Pawson, currently a leading author in the field ).
Critical realism as explained by Bashkar begins with the notion that scientific inquiry is more than observation and the measurement of facts. It starts from an assumption about complexity . Social phenomena are built from the actions of actors and by their interpretation of these phenomena. Actors are constrained or enabled by social structures. The interplay between agents and structures influences the working of interventions, and research should try to understand how agent–structure interactions produce social change . The realist approach proposes a systematic integration of contextual analysis in the synthesis and evaluation of interventions. It asserts that it is not the intervention that generates outcomes, but rather that the mechanisms in certain contexts produce outcomes . Therefore, the influence of context and the mechanisms it triggers, implies that an intervention might work well in one context but not in another . Mechanisms refer to the reasoning and behavior of participants and stakeholders in an intervention. Context-mechanism-outcome (C-M-O) configurations produce a ‘generative explanation for causation’ . Interventions, such as those promoting social accountability, can influence the course of change within society, but will never on their own lead to change .
A realist synthesis aims to provide explanations for successes or failures but does not aim to generate judgments [25, 26, 28]. Realist synthesis is grounded on program theory, which is crucial for moving beyond ad hoc or piecemeal explanations . Through a synthesis process, the program theory or theories are tested and further refined by identifying how contextual factors (C) influence the production of outcomes (O) through the triggering of specific mechanisms (M) in the form of context-mechanism-outcome (C-M-O) configurations [28, 29]. These C-M-O configurations may constitute patterns, called demi-regularities, which in turn support or contradict program theories. Program theories can be further synthesized and generalized to form middle-range theories (MRTs). MRTs help to develop a level of abstraction needed to understand the diversity of outcomes across contexts . In this review, the processes through which social accountability leads to change might have some universal characteristics, although their application will be adapted to local contexts.