Table 1 Framework for data extraction

Realist review concepts

Context

Actors or factors that are external to the intervention, occurring independently of the outcome or influencing the outcome [32]. “Context can also be understood as anything that can trigger and/or modify the behavior of a mechanism” [33].

Issue/problem: The issues citizens are confronted with or about which they express demands, claims, suggestions, opinions, preferences and so on. For example, they may be about the quality, acceptability, accessibility or availability of health services and policies, equality (gender, class or ethnicity) or particular medical aspects of the citizen–provider interaction (disease recognition, treatment and so on) [34]. The issues at stake may also be about equity, discrimination, exclusion and demands for changes in the underlying power relations.

Political/institutional factors: The nature and strength of civil society; models of deliberation, information, capacities and awareness of citizens; the strength of the health system; the capacities, power and incentives of providers and policymakers; the nature and scope of existing social accountability relations; the legal context of citizen engagement; media and press; the historical context; pre-intervention activism; political economy factors; formal and informal political processes; general views on participation; cultural norms and the history of the community where the intervention is implemented [33, 34].

Other interventions: Other participatory interventions, government-led accountability initiatives, initiatives to strengthen citizen participation in general or for health.

Mechanism

Interplay between structure and agency, how the social structure interacts with individual or group agency. Mechanisms can be found at individual, group, organizational or societal levels. They are psychological or social explanations of behavior. They may be the cognitive or emotional responses of people who want to participate (or not) in an intervention. They are not intervention strategies, which are intentional measures taken by program implementers [32, 33]. Mechanisms are defined as elements of the reasoning of the actor facing an intervention [26, 29].

In documents they may be referred to as barriers or facilitators and/or successful or unsuccessful elements of the intervention and its outcomes. They are most likely presented in the discussion or lessons learned section. Mechanisms may be expressed through interpretations, considerations, decisions or behaviors of humans, including the authors of a document. Within the factors being discussed, the behavioral elements will need to be distilled. In the context of citizen engagement and social accountability, mechanisms may refer to triggers that make a citizen or a provider decide or act in favor or not in favor of the intervention. His/her considerations may be a simple cost–benefit analysis, the expected success for the individual or the collective, the mandate of the activity, the trust in, and behavior of the facilitators, and so on.

Outcome

Intended or unexpected outcome of an intervention. It can be defined as intermediate or final [33]. It can be reported at the individual, organizational, institutional, policy or legislative level. It can be both positive and negative.

The reviewers distinguish between process outcomes and health, rights and development outcomes (called impact). Process outcomes can be found on the citizens’ side and on the providers’ side. For citizens, outcomes can be levels of empowerment, voice, agency, awareness, knowledge, satisfaction, trust. Change in providers’ and policymakers’ responsiveness can be levels of accountability: receptivity, responsibility, recognition of issues and concerns, inclusion, acceptance, discrimination, coherence, cohesion, confrontation, conflict, trust, quality and performance (e.g. related to accessibility, acceptability) reflected in changed behavior, policies and practices. Impact refers to health outcomes such as increased utilization of or attendance at health services, prevalence and treatment rates.

C-M-O configurations

A C-M-O can pertain to a whole program or parts of it and one C-M-O can be embedded within another. They can also be configured in a series where the outcome of one C-M-O constitutes the context for the next [33].

Example with responsiveness as an outcome: a set of mechanisms (M) that influence health providers’ and policymakers’ responsiveness vis-à-vis citizens preferences and demands (O) that are triggered by criticism in mass media and contextual factors such as the openness of the health system to public opinion (C).

Social accountability

Social accountability is sometimes understood in terms of tools, in other instances, it refers to social and political processes of the citizen–state interaction. The reviewers will consider the effectiveness of the process; it will need to be analyzed in the wider intervention context and the context of the processes of citizen engagement and oversight mechanisms that are part of it. Citizen oversight is the ability of citizens to influence the quality or equity of health services and policies through the use of, or supported by, pressure or accountability mechanisms. There is a notion of collective action. The more activist definition is ‘collective challenges to medical policy and politics, belief systems, research and practice that include an array of formal and informal organizations’. Challenges are to political power, professional authority and personal and collective identity’ [35].

See interventions below.

Social accountability intervention

For this review, the authors distinguish between two types of interventions (see inclusion criteria):

1. Explicit social accountability interventions are interventions that aim to empower citizens to articulate, voice and express their concerns regarding service delivery with the aim of transforming provider organizations or policymaking institutions. They most probably are initiated or driven by citizens and they most likely involve collective actions by associations or groups of citizens (and not by individuals).

Examples of explicit social accountability interventions: Strategies aimed at enhancing citizen engagement and oversight (see above) through approaches such as information campaigns about rights and entitlements, performance standards, collecting and reviewing evidence, collective monitoring (public hearings, opinion polls, citizens’ juries, community scorecards, social audits, citizen report cards and so on), mobilization and advocacy [4, 10]. They may also include more informal or spontaneous actions such as protest, petitioning, strikes, strategic non-participation or the use of cultural symbols [34]. These processes may be facilitated by an intermediary structure (Community Health Worker, non-governmental organization or civil society organization, health committee or local council). Decentralization and devolution reforms will be included as they aim explicitly at strengthening local citizen–state relations, voice and responsiveness.

2. Implicit social accountability interventions are strategies that citizens, health providers or policymakers undertake to influence or change their relation with citizens. Rather than having an explicit aim to strengthen citizen voice and accountability, these elements of social accountability are reported or observed in the process or the outcomes. They are most likely initiated by governmental agents or providers themselves and most likely concern individual patients.

Examples that implicitly address (elements of) social accountability: 1) providers and policymakers may introduce participatory planning, monitoring and evaluation techniques, share information or seek citizens’ opinions (client satisfaction surveys, participatory maternal death audits or complaint mechanisms); 2) outreach and health education strategies that include interventions that aim to raise awareness and change health behavior. They are most likely focused at increasing access and coverage 3) health insurance and community financing using community resources (land, labor or money) to increase access or reduce the costs of providing services. In these cases, the main focus of the intervention is on financing, not on citizen–provider–policymaker relations [15]. These three examples of interventions will be excluded in the first round of this review because the reviewers expect that they do not aim at, or result in, citizen engagement or oversight, or provider and policymaker responsiveness.

Actors

Studies may define the actors involved differently, but they can probably be identified as being on the citizen side or on the provider or policymaker side.

A distinction will be made between the initiators/implementers and target groups/participants as well as the intermediary structures if relevant.

Program theory

A mostly implicit set of assumptions that steers the choice and design of an intervention. It is the black box between the intervention and the outcome; it explains how and why the intervention is expected to produce outcomes [25, 32].

The reviewers will use their own preliminary program theory to assess the evidence in the literature. As part of the assessment however, they will also report on the program theory of the interventions studied (see review questions).

Middle-range theory (MRT)

‘A program theory is considered middle range when it is capable of retaining its relevance across multiple cases and in differing contexts’ [33].