Social Accountability

What it is

What others have done

What to ask

How to succeed

What should I know before beginning implementation?

In practice, social accountability can include a variety of initiatives and activities. What makes an initiative “social accountability” is that it relies on citizen engagement and voice to hold governments and service providers accountable. Generally, the various forms of social accountability fall into one of three categories: democratic accountability, performance accountability, and financial accountability, each described in the drop-down below. Within each type, research suggests four necessary components to maximize opportunities for success: transparency of necessary data, top-down responsiveness, representative participation, and citizen-led oversight (discussed further below).

Democratic accountability includes systems, laws, and contexts that build an enabling environment for citizen-led accountability. Traditionally, democratic accountability is thought of as comprising free and open elections and the existence of freedom of information laws ² (for more information from USAID, see this resource on vertical democratic accountability). For the purpose of strengthening PHC, we broaden this definition and consider democratic accountability to be initiatives by governments to open up space for citizen monitoring of the health system.
Democratic accountability initiatives often include a combination of transparency and responsiveness efforts.
- Transparency: “Transparency is about shedding light on rules, plans, processes and actions. It is knowing why, how, what, and how much. Transparency ensures that public officials, civil servants, managers, board members and businesspeople act visibly and understandably, and report on their activities.”³
  - An example of transparency is the release or publication of the data and information needed for citizens to monitor the health system. For instance, open contracting for health procurement ⁴ includes publishing contracting processes and payments for procurement of medicines, medical equipment, medical infrastructure, etc. to allow public oversight on how these contracts are finalized. Another example is open data initiatives ⁵ that publish government administrative data on budgets, expenditures, and health and performance indicators. Overall, the purpose of these initiatives is to provide enough information to civil society to enable them to effectively monitor the health system.
- Responsiveness: Responsiveness initiatives include government actions to respond to needs or requests that arise during citizen monitoring.
  - One such example is a supreme audit institution within the government that takes forward and investigates claims or asks by citizens.⁶ Supreme audit institutions provide civil society with a national-level ally that has the power to ensure that government actors at all levels of the system are budgeting and utilizing funds properly. A less formal but equally important national accountability actor in some countries is the ombudsman’s office. In addition to national actors, many countries incorporate programs or institutions for responsiveness at the sub-national level, such as institutionalize social audit programs and community development committees through which local governments work with civil society to jointly monitor elements of the health system. For example, in Zimbabwe, a citizen-led monitoring effort led to the creation of an interface monitoring committee made up of local government officials as well as citizens.⁷ Local civil society organizations that supported this program credit activities that educated citizens of their rights regarding waste management (the focus of the monitoring effort) and the early and intensive involvement of local government officials in the program as key reasons for its success.
Performance accountability is defined as initiatives and actions by citizens and civil society organizations (CSOs) to hold government actors and service providers accountable for their performance through bottom-up monitoring and engagement ² (for more information from USAID, see this resource on vertical democratic accountability). This includes participation of community members and mechanisms to hold administrators and policy makers accountable to the needs of the people. Performance accountability makes up the majority of social accountability initiatives and encompasses what is often considered “traditional” social accountability interventions such as citizen scorecards, citizen oversight committees, and watchdog organizations.
An example of a performance accountability initiative is the Uttar Pradesh Health Systems Strengthening Project for India, which aims to improve the efficiency, quality, and accountability of health services delivery by strengthening the state health department's management and systems capacity.⁹ A key component of this initiative was to introduce and strengthen social accountability interventions in order to stimulate community action to demand better services, enhance positive health behavior, and promote social audits of service delivery and resource allocation.¹⁰ One component of this intervention includes an information and awareness campaign. A second component involves community members monitoring primary health care services, addressing concerns to village representatives, and participating in preparing a village scorecard that rates the quality of the health services they receive.
Financial accountability is defined as initiatives and actions by citizens and CSOs to track leakage and mismanagement of public budgets and expenditure within the health system. In practice, this process is quite similar to performance accountability with a different set of outcomes, namely monitoring of expenditure of funds for services. Like performance accountability, it includes a combination of activities that encourage participation of community members and mechanisms to hold those in the system accountable to the needs of the people. Financial accountability includes initiatives such as public expenditure tracking surveys, participatory budgeting and planning, and budget transparency initiatives.
In Mexico, for example, the civil society organization Fundar (Centro de Análisis e Investigación) developed an advocacy project called Health, Citizenship, and Human Rights. Within this initiative, Fundar initiated a monitoring strategy to address a series of specific budgetary issues affecting Seguro Popular, the agency tasked with providing healthcare to the country’s 52 million uninsured.¹¹ Over time, the budget and expenditure tracking effort provided a foundation for advocacy and policy change within Seguro Popular to improve health service delivery. Fundar specifically focused on two key outcomes: introducing specific policies to ensure sustainable and consistent public reporting of the health budget to ensure that active civil society organizations could regularly track health expenditures and building their own internal capacity to act as a leader in national advocacy for equitable financing for health services. Both of these components of the project were critical to ensuring that the right information and the right actors to act on this information were in place to achieve better spending for health in Mexico. More information on this project can be found here.
Social accountability works best with coordinated efforts from two key sets of actors: those with decision-making power, and citizens or civil society. Those who have decision-making power in health policy (governments and institutions) can work from “above” the point of frontline service to ensure that actions, decisions, and resources for primary healthcare are effective and equitable (top-down actions). Citizens and civil society can monitor and advocate for better services as patients from “below” the point of frontline service delivery and can play a critical role in observing and voicing local challenges in primary healthcare that require attention (bottom-up actions). While these accountability approaches are framed as bottom-up and top-down, accountability is likely to be most effective when it also brings in the voices and experiences of service providers themselves on the frontline. Therefore, the four necessary components of social accountability include transparency of necessary data, top-down responsiveness, representative participation, and citizen-led oversight.
Top-Down
The success of social accountability initiatives is dependent on the government and institutions opening space for citizens from above, which includes ensuring the transparency of information and top-down responsiveness from government officials and private institutions. The WHO Framework for Integrated People-Centered Health Services states that “governments need to take responsibility for protecting and enhancing the welfare of their populations and to build trust and legitimacy with citizens through effective stewardship. The stewardship role of the health ministry is essential for good governance in health and involves the identification and participation of community stakeholders so that voices are heard and consensus is achieved”.¹² Two key top-down components of social accountability are transparency and responsiveness.
- Transparency: This includes transparency of data needed to monitor the health system, including disclosure of relevant health indicators, budget allocation and expenditure reports, and health system performance indicators. Transparency is a necessary step, but opening data is not enough.² ¹³ ¹⁴ Transparency must be paired with the other three necessary components in figure 2 above.
- Top-down Responsiveness: This refers to government institutions and actors being open and responsive to citizen voice and feedback. This responsiveness could take the form of sanctions to react to a grievance voiced by health system users in order to enforce changes in policy or practice based on citizen feedback (reactive). It could also include integration of social accountability into health system processes (proactive), such as embedding community representatives within the formal monitoring of health clinic performance.¹⁵
Bottom-up
Social accountability is mainly driven by action from citizens and health system users. Necessary components of social accountability from below are representative participation and citizen-led oversight.
- Representative Participation: This refers to participation of an inclusive sample of the users of a health system in social accountability activities, including diverse representation of men and women, vulnerable, and at-risk populations. Representative participation seeks to ensure that the voice emerging from the community accurately represents the users of the system. It is essential to ensure that those participating in social accountability efforts do not only represent community elites; “elite capture” risks further amplification of voices already empowered and further marginalization of voices not usually heard. PHC oversight efforts should also prioritize selection of community members who are independent of the health system administration to assure objective monitoring.¹⁶ One essential component of representative participation is community engagement, detailed further within the population health management module.
- Citizen-Led Oversight: This includes the citizen- and/or CSO-led interventions to conduct PHC monitoring and oversight. In practice, this could include initiatives such as oversight committees or participatory budgeting. To do this well, CSOs and citizens should have relevant capacity and access to necessary tools and data. Depending on the initiative, this may be technical capacity to analyze and understand financial or other data, ability to communicate with media or relevant stakeholders, etc.

PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content on this website represents the position of the partnership a whole, it does not necessarily reflect the official policy or position of any partner organization.

What have others done to improve social accountability in primary health care?

The case studies included below are a small sample of social accountability interventions. To show examples of the type of impact social accountability can have on health outcomes, most of the highlighted cases are examples of successful social accountability interventions. However, the evidence on the impact of social accountability initiatives is largely mixed, and much of the empirical research in social accountability has focused more explicitly on whether specific interventions work in specific places rather than why or how those interventions work or fail. Several systematic evidence reviews of social accountability seek to fill this gap by assessing trends and theoretical framing for best practices in social accountability, including Fox ¹ and Danhoundo et al.¹⁷ The best practices derived from these reviews are presented in the “What it is” section.

It is also important to note that two of the following case studies have a financial angle. Part of the reason is that social accountability is a relatively new field which stemmed from financial tracking efforts. Therefore, some of the most developed case studies on this topic are in the financial sector. Please see Fox¹ and Danhoundo et al.¹⁷ for a review of additional case studies.

In 2014, a CSO in Nigeria implemented a financial accountability initiative to improve health system outcomes through strengthened infrastructure.⁴ Taking advantage of the Freedom of Information Act, the Public-Private Development Centre (PPDC) tracked expenditures for procurement in the construction of 40 Primary Health Care Centers (PHC Centers) by the Nigerian Primary Health Care Development Agency. To do this, the PPDC team formed a unique collaboration with a university, procurement specialists, and a newspaper. As the technical support partner, the Pan Atlantic University helped to organize budget data from multiple sources. Data journalists from the Premium Times Centre for Investigative Journalism analyzed the data to determine value for money in the procurement process. The PPDC published the information on an open procurement platform called Budeshi. Finally, the PPDC partnered with procurement monitors to visit PHC sites to monitor and match up construction status with financial records.
Through this process, PPDC discovered that only 36 percent of expenditures that were set aside to build new facilities resulted in operational facilities. They also found that funds budgeted to build new PHCs exceeded the amount that was contracted; while this initially may appear to be a case of cost savings, only five of the seventeen new PHCs with the largest 'savings' (of 33 to 54 percent) were operational, indicating that the funds may have been misused. Tracking these funds, PPDC found that the winning bid of 26 contracts were all of the same amount. This suggested either that the companies had coordinated on the bidding amount or, more likely, that they are all contracted to the same company under different names. According to Nigerian law, bidders must participate in open and competitive tendering, and this initiative uncovered evidence that competitive tendering may have been compromised. The initiative found that the government construction of PHCs was at best extremely inefficient and at worst suffered from corruption and collusion.
After PPDC shared the results with the Nigerian government and in conjuction with the Health Minister announcing the construction of 10,000 new PHCs, the Nigerian government has pledged to use open contracting in new procurement. PPDC also received a grant from donors to continue development of the open contracting platform, Budeshi, to continue this type of civil society-led monitoring.
Citizen report cards promote performance accountability by creating feedback loops on quality of care – including amenities, waiting times, respectful care, and availability of providers and drugs -- between citizens and the health system. One way in which these report cards can improve outcomes is by shifting the incentives for service providers to be directly responsive to health system users. Bjorkman et al. tested the impact of this strategy by conducting a randomized control trial of citizen report cards in 50 facilities in Uganda.¹⁸ The intervention began with surveys of 5000 households to understand health outcomes and health system performance. Researchers analyzed the data along with health facility records to create a report card on key health performance subjects (utilization, quality, etc.). Next, researchers shared these results with the village members and health facilities through a series of village meetings and events, aiming to draw as much participation as possible. Finally, researchers set up representative interface meetings between citizens and health facility staff to identify strategies to improve performance. Following this experiment, there was 30 percent turnover of local Health Unit Management Committee representatives, whose role it is to monitor the health system on behalf of user. This indicated that the program was successful in increasing participation in the health system and in holding committees accountable. Performance indicators also improved, including increased utilization, decreased wait times, decreased absenteeism, and increased cleanliness of facilities. There was also a statistically significant impact on child mortality rates. Overall, the use of citizen report cards in this context led to improvement in the quantity and quality of care.
While this study reveals the potential of these types of performance accountability initiatives, it is worth noting that many other evaluations of similar programs find mixed or null results. For example, the Transparency for Development program led by Results for Development and the Harvard Kennedy School conducted a similar study in five countries using an adapted community scorecard intervention.¹⁹ This research revealed that a similar community scorecard to the one tested by Bjorkman et al. failed to show an impact of the intervention on health outcomes in two countries (Tanzania and Indonesia). This and other studies highlight the need for more research on why and how social accountability programs like this one succeed or fail.
Effective primary health care should involve community participation in all aspects of service delivery.²⁰ However, there is often a mismatch of power between health system administrators and health system users, especially in the budgeting process. Participatory budgeting can help align budgets to the needs of the population by building citizen feedback directly in the budgeting process. Participatory budgeting also improves information flows between policy-makers and citizens.
An assessment of participatory budgeting in Brazil from 1990 to 2004 shows increased participation by citizens over time as well as participation becoming increasingly representative over time.²¹ As a result of this approach, budgeting trends also shifted within municipalities with a larger share of budgets being allocated to health and sanitation. This change is correlated with a reduction in infant mortality rates. This suggests that promoting a more direct interaction between service users and elected officials in budgetary policy can affect both the allocation of local resources and health outcomes. By providing not just a voice but also power to make budgeting decisions to citizens, service users and those who experience the biggest problems and priorities in their communities on a daily basis can ensure that those are the problems and priorities that are being addressed.

What questions should be considered to begin improvements?

The questions below may be a useful starting place for determining if Social Accountability is an appropriate area of focus for a given context and how one might begin to plan and enact reforms:

What systems for social accountability (if any) already exist in the system?: Even if there are no social accountability initiatives integrated specifically into the health system, there may already be initiatives on the ground supporting performance and financial accountability more generally. Identifying any existing ongoing initiatives in communities can help both the health system and the initiatives to improve effectiveness. There may also be government-wide democratic accountability initiatives in place that impact the health system. For example, many countries have open procurement systems, but citizens and civil society organizations may not currently be using these systems to monitor health procurement decisions. Understanding these systems and any potential synergies is a good first step.

Do ongoing initiatives have all four necessary components for success?: The literature suggests that a bundled approach of top-down and bottom-up efforts increase the likelihood of success for social accountability initiatives. There may be social accountability initiatives underway in primary health care that are missing critical pieces to maximize effectiveness. In some cases, this gap may be the lack of linkages from citizen reporting to government bodies for top-down accountability. In other cases, this could be insufficient capacity of CSOs. Identifying these gaps can help those supporting social accountability to understand how to strengthen and further develop these initiatives.

Who should play a formal role in the social accountability program?: While social accountability by definition requires the voice and participation of civil society, citizens and other actors (such as media and CSOs) can play important roles in these initiatives as facilitators, brokers, and information sharers. In addition, identifying government champions who are interested in listening to and incorporating the voices of citizens into their decisions can help improve the likely impact of social accountability.

What are the core problems that communities and civil society care about in primary healthcare that should be the focus of social accountability efforts?: Different social accountability tools are designed to address different types of problems within the health system; for example, citizen report cards are well-suited to identifying problems with client experience with frontline service providers whereas social audits are better suited to identifying places where budgeting (especially for infrastructure and supplies) has not been properly used. Current best practice is to employ a holistic and strategic approach to social accountability rather than a tool-based approach; however, it is important to design any program to fit the actual problem(s) on the ground – or to identify these problems.

Are there existing institutions that can help to support social accountability?: Government programs and institutions outside of the health sector may be important allies and/or resources for new social accountability programs. For example, supreme audit institutions and the justice system can help to support initiatives that seek to hold actors accountable for corrupt practices, and open contracting and e-procurement programs can help ensure that corruption is avoided before it can occur.

What elements should be in place to support effective improvements?

In order for interventions aimed at improving Social Accountability to be most successful, the following elements of the PHCPI Conceptual Framework should be in place or pursued simultaneously: